A Synergy staff member may ask you to print and complete one or more of the following forms prior to your first visit.

Back Index

This questionnaire will give your Synergy provider information about how your back condition affects your everyday life.

Neck Index

This questionnaire will give your Synergy provider information about how your neck condition affects your everyday life.

Disabilities of the Arm, Shoulder, and Hand (DASH) Assessment

This questionnaire rates your ability to perform certain activities with your arms, shoulders and hands.

Lower Extremity Functionality

This forms helps us assess if you are having difficulty performing certain activities due to a lower limb injury or dysfunction.

Contact one of our two Colorado Springs locations to schedule your first consultation appointment with one of our therapy specialists.



North Office (map)
4105 Briargate Parkway
Suite 255
Colorado Springs, CO 80920
phone 719.282.2320
fax 719.282.2330


South Office (map)
600 South 21st Street
Suite 130
Colorado Springs, CO 80904
phone 719.634.1110
fax 719.634.1112

After you make an appointment, be sure to fill out our patient and history forms by clicking on the appropriate clipboard above. Providing this information will greatly expedite your first visit and also help your therapist prepare for your exam and treatment.

When filling out these forms, be sure to have the following information:

  • Referring provider name (if applicable)
  • Primary care provider information
  • If work or auto injury, your claim number
  • Primary insurance provider information
  • Secondary insurance provider information (if applicable)

If you are having problems filling out the forms, please print and complete our New Patient and Consent forms. Please bring these with you on your first visit!

What To Expect On Your First Visit

What should I bring to my first visit?

You need to bring a picture ID, Military ID (if applicable) and Insurance card(s). Please fill out the patient paperwork prior to your first visit. You may also bring any diagnostic tests (MRI, X-ray or other) and the associated reports, which may aid your therapist in the evaluation process.

What do I wear?

Lose fitting and comfortable clothes, which allow the therapist to access your injured body part(s).

Should I arrive early to the first visit?

You should allow 15-30 minutes of time prior to your visit if you haven't finished your paper work.

What do I need to bring? How long will my visit last?

The first visit is primarily an evaluation process, thus the nature of the injury, number of body parts involved and complexity of the history can change the length of the visit. In general, expect to be here for an hour.

How long will subsequent visits last?

Different diagnosis and the number of body parts treated my increase or decrease your average visit time. We expect you to allow 45 minutes to an hour for each visit, but some may be far shorter if the goals of the treatment are met.

How long will I be coming to physical therapy?

The average number of visits for physical therapy is around 10-12 visits nationally. This does not take specific diagnosis into account, thus a light ankle sprain may take 3 visits, a severe ankle sprain may take 10 visits and an automobile accident which causes hospitalization and multiple surgeries might take 40 visits. Make no mistake, our primary goal is to get you back to normal function as soon as possible.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    1) Uses and Disclosures
  • We will use your protected health information (PHI) for the purposes of treatment, payment and health care operations.
  • Treatment includes the disclosure of health information to other providers who have referred you for services or are involved in your care. This may include doctors, nurses, technicians and other physical therapists.
  • Payment includes the disclosure of health information to your insurance company, including Medicare, so payment can be obtained for services rendered. Your insurance company may make a request to review your medical record to determine that your care was necessary.
  • Health Care Operations includes the utilization of your records to monitor the quality of care being given at our facility or for business planning activities.
  • Other Special Uses
  • Our practice may use your PHI to send you an appointment reminder and/or to inform you of our other health-related products and services.
  • Uses and Disclosures Required by Law
  • The federal health information privacy regulations either permit or require us to use or disclose your PHI in the following ways: we may share some of your PHI with a family member or friend involved in your care if you do not object, we may use your PHI in an emergency situation when you may not be able to express yourself, and we may use or disclose your PHI for research purposes if we are provided with very specific assurances that your privacy will be protected. We may also disclose your PHI when we are required to do so by law, for example by court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions.
  • We may use and disclose health information about you to avert a serious threat to your health or safety or the health or safety of the public or others. If you are in the Armed Forces, we may release health information about you when it is determined to be necessary by the appropriate military command authorities. We may also release information about you for workers' compensation or other similar programs that provide benefits for work-related injury or illness.
  • Your authorization is required before your PHI may be used or disclosed by us for other purposes.
    2) Your Privacy Rights
  • Restrictions
  • You have the right to request restrictions on how your PHI is used, however, we are not required to agree with your request. If we do agree, we must abide by your request.
  • Confidential Communications
  • You have the right to request confidential communication from us at a location of your choosing. This request must be in writing.
  • Access to PHI
  • You have the right to request a copy of your medical record. You must make this request in writing and we may charge a fee to cover the costs of copying and mailing.
  • Amendments
  • You have the right to request an amendment be made to your PHI, if you disagree with what it says about you. This request must be made in writing. If we disagree with you, we are not required to make the change. You do have the right to submit a written statement about why you disagree that will become part of your record. We may not amend parts of your medical record that we did not create.
  • Accounting of Disclosures
  • After April 14, 2003, you have the right to request an accounting of the disclosures made in the previous six years. These disclosures will not include those made for treatment, payment, or health care operations or for which we have obtained authorization.
  • Complaints
  • If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.
  • Our Duty to Protect Your Privacy
  • We are required to comply with the federal health information privacy regulations by maintaining the privacy of your PHI. These rules require us to provide you with this document, our Notice of Privacy Practices. We reserve the right to update this notice if required by law. If we do update this notice at any time in the future, you will receive a revised notice when you next seek treatment from us. Please visit http://www.synergympt.com/.
  • Privacy Contact
  • If you would like more information about our privacy practices or to file a complaint you may contact our Privacy Officer, Kelly Haddock at 719-495-7383.
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