FORMS

Serving Los Angeles & Orange Counties.

Your Name:

Phone number you consent to receive texts/calls:

Email:

I would like: (Bodywork-only sessions offered after initial eval or if already seeing another provider for developmental treatment)

An In-Home Pediatric Evaluation $400

An In-Home Fascial Bodywork session $250

Clinic Fascial Bodywork session $180

I want to discuss my child's specific needs and speak with Dr. Hazel Legaspi, PT to assist our family in taking next steps.

Schedule a 30 minute phone consultation $50

How did you hear about us?

Info you want us to know, your concerns, goals:

The best days and times you are available for the service (phone consultations, evaluations, sessions) you are requesting:

City & Zip Code

(Previously Dr. Legaspi Synergy Physical Therapy)

Pediatric & Family Physical Therapy

in the Comfort of Your Home!