Name *

First Name

Last Name

Parents/Guardian Name(s) (if under 18):

First Name

Last Name

Cape Cod Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ideal Day for Assessment/Sessions *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Ideal Time(s) for Assessment/Sessions *

Early Morning

Morning

Late Morning

Noon

Afternoon

Evening

Do you live on Cape? *

Yes, year round

Yes, seasonally

No, just visiting

Ideal Location for Sessions *

My House

Outdoors in mutually agreed upon location

Other (please provide info below)

Do you have pain? *

Yes

No

Do you have an Injury? *

Yes

No

Interests in Working with Movement by Logan

Choose as many as you'd like

Physical Therapy

Fitness Training

Mindfulness Practices

Spiritual Exploration - Meditation, Discourse, etc.

Hiking/Nature Exploration on the Outer Cape

Other

I am aware that Movement by Logan does not accept any insurance and I agree to pay "out-of-pocket" *

Yes

I am aware that there is an additional charge per session for driving distances greater than 10 miles. An additional $15 up to and per 10 miles from the Eastham Library *

ie 11-20 miles = $15; 21-30 miles = $30

Yes