Pelvic Floor Therapy intake that captures primary concern and referral
Every pelvic floor therapy enquiry captures the patient's primary concern, referral status, and symptom duration alongside their referral letter, so you know who's ready for an appointment before you confirm one.
The exact intake your pelvic floor therapy leads complete
This is the real 5-question guided intake for Pelvic Floor Therapy — the same flow your customers finish before you ever pick up the phone.
What a qualified pelvic floor therapy lead should tell you
Specialized physical therapy targeting pelvic floor muscle dysfunction, qualified by the patient's primary concern (bladder, bowel, pain, postpartum, or surgical recovery), referral status, symptom duration, and pregnancy status.
- Primary Concern Want Addressed
- Doctor Or Midwife Referred
- Long Have Been Experiencing
- Pregnant
- Had Any Prior Pelvic
The questions your team needs answered
Every pelvic floor therapy intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| What is the primary concern you want addressed? | The primary concern carries the heaviest weighting in the catalog, with bladder control, pelvic pain, and bowel control issues scored highest at 7-9 and 'other concern' scored lowest at 5. |
| Has a doctor or midwife referred or recommended you for pelvic floor therapy? | A physician or midwife referral adds three points over a self-referral (7 vs. 4), reflecting that referred patients typically arrive with a clearer clinical picture. |
| How long have you been experiencing these symptoms? | Symptom duration has no assigned weight, but it gives the clinic chronicity context to review alongside the scored primary concern. |
| Are you currently pregnant? | Pregnancy status isn't weighted, but it's a clinically important flag for deciding whether a patient needs a prenatal-specific evaluation path. |
| Have you had any prior pelvic floor therapy or evaluation? | Prior pelvic floor therapy history isn't scored, but it helps the clinic tell new evaluations apart from returning patients before the first appointment. |
How Cliont scores pelvic floor therapy leads
Every answer is weighted automatically — no manual review required.
Value signals
- Pelvic or lower abdominal pain
- Bowel control or constipation issues
- Postpartum recovery
- Pre or post pelvic surgery recovery
- Other concern
- Doctor Or Midwife Referred: yes
Urgency signals
- Bladder control or leakage
See the lead your team receives
Pelvic Floor Therapy Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for pelvic floor therapy workflows
| Cliont capability | Pelvic Floor Therapy application |
|---|---|
| Referral-aware routing | Flags whether a patient was referred by a doctor or midwife so front-desk staff can follow up on missing referrals before the appointment is confirmed. |
| Pregnancy status capture | Surfaces current pregnancy status at intake so clinics can route prenatal patients to the right protocol instead of a standard evaluation slot. |
| Returning-patient detection | Uses the prior pelvic floor therapy question to separate new evaluations from returning patients who may need a different intake path. |
| Concern-based prioritization | Sorts leads by primary concern weight, putting bladder control, pelvic pain, and bowel control cases ahead of lower-weighted 'other concern' submissions. |
Common pelvic floor therapy lead scenarios
Postpartum patient, no referral yet
Selects postpartum recovery as the primary concern but hasn't seen a doctor, so the intake flags the missing referral for front-desk follow-up before scheduling.
Pre-surgical referral, short symptom window
A physician-referred patient preparing for pelvic surgery reports symptoms under a month old, giving the clinic a clear referral trail and timeline for care planning.
Currently pregnant, reporting pelvic pain
Pregnancy status combined with a pelvic pain concern lets the clinic apply the right prenatal protocol or route to a specialist instead of a standard evaluation slot.
Long-standing leakage, self-referred
Symptoms present for over a year with no doctor referral and no prior pelvic floor therapy, useful for identifying self-directed patients who may need insurance or authorization guidance first.
Returning patient, bowel control concern
Has had pelvic floor therapy before and is referred again for bowel control issues, distinguishing a known patient from a first-time evaluation.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More physical therapy intake templates
Pelvic Floor Therapy lead-intake FAQs
Does the intake require a doctor's referral before a patient can book?
The intake asks whether the patient was referred by a doctor or midwife, but it doesn't block booking either way. Referred patients score higher (weight 7 vs. 4 for self-referred), so your team can prioritize or set different intake steps for each group.
How does the intake handle pregnant patients?
Pregnancy status is captured as a direct yes/no question so your team knows before the appointment is confirmed, letting you route the patient to a prenatal-specific protocol or provider rather than a standard slot.
What if the patient has already had pelvic floor therapy before?
Prior pelvic floor therapy or evaluation is captured as a flag so returning patients can be distinguished from first-time evaluations, even though it isn't part of the numeric score.
Which primary concerns are treated as higher-priority leads?
Bladder control or leakage and pelvic or lower abdominal pain carry the highest weight (9), followed by bowel control issues, postpartum recovery, and pre/post pelvic surgery recovery (7-8). 'Other concern' scores lowest at 5.
Does how long the patient has had symptoms affect their score?
Symptom duration is collected for clinical context but has no assigned weight, so it won't push a lead's score up or down — it's there for your team to review alongside the primary concern.
Can this same intake be used for pre or post pelvic surgery patients, or should I use Post-Surgical Rehabilitation instead?
If the surgery is pelvic-specific, the pelvic floor therapy intake already includes 'pre or post pelvic surgery recovery' as a primary concern option. For other surgical sites, the Post-Surgical Rehabilitation subservice catalog is the better fit.
Turn pelvic floor therapy visitors into qualified patients
Give every pelvic floor therapy visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.