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Adult Myofunctional Exam

Welcome to Mind Body Myo!

This intake form takes about 10-15 minutes to complete. Please take your time and answer each question as thoughtfully and honestly as you can. Your responses help me understand your unique needs and determine how I can best support you. Thank you for being here and for taking this step toward greater health and well-being.

First Name

Last Name

What's your date of birth?

What's your age?

How did you hear about me?

What inspired you to reach out for myofunctional therapy?