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New Client Intake

Felt Health LLC

dba Julia de Castro DPT

Help tailor our first session together by sharing some background.

Kindly answer to the best of your ability. I must hear your response to each question.

Current Symptoms

1 = No Pain 10 = Worst Pain

Have you tried other treatments for this issue (check all that apply):
How did you hear about me (check all that apply):

Medical History

Any recent surgery or procedure related to your current symptoms:
No
Yes
Have you had any recent falls?
No
Yes
Have you experienced: (check all that apply)
Have you been diagnosed with: (check all that apply)
Do you have any imaging findings for your current complaint?

We'll discuss findings in person.

Any other health conditions I should know?
No
Yes

Goals & Interests

What are your top goals for your visit (select all that apply):
Do some of my offerings interest you more than others? (check all that apply):

Microcurrent Related Information

Do you have any of the following conditions which would prevent you from receiving microcurrent therapy? (Select all that apply)
Have you received any cortisone, botox or filler injections in the past 10 weeks?
No
Yes
N/A

Release and Waiver

I understand that all my information provided is confidential and will be handled in compliance with HIPAA regulations.


Microcurrent Disclaimer

I understand that microcurrent therapy is a complementary therapy and is not a substitute for medical care. I acknowledge I have provided accurate and complete health information. I understand the contraindications to receiving microcurrent therapy indicated above, and I affirm it is my responsibility to deny treatment should any of those conditions apply.


Should I choose to receive microcurrent therapy, I release Felt Health LLC and its practitioners from any liability resulting from the therapy provided.

Consent to Services

I understand that Felt Health LLC provides wellness services including manual therapy and Equiscope® microcurrent therapy, and that while sessions may offer therapeutic benefits, no guarantees or assurances have been made regarding specific outcomes.

By signing this document, I hereby recognize my:


  1. Release of Liability: I voluntarily release and hold harmless Felt Health LLC, its owner, employees, contractors, and agents from any liability, claims, or damages resulting from my participation in these services, including the use of Equiscope® and micro-current technology.

  2. Client Responsibility: I acknowledge it is my responsibility to consult my physician regarding any health concerns or potential contraindications prior to receiving services.

  3. Informed Consent: I confirm that I understand the nature of receiving sessions, including the potential for temporary detoxification or other mild symptoms as part of the process.

Adult or Minor

I have read, fully understand, and voluntarily agree to this Release and Waiver.

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