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Clinical Sites for Students

Please tell us about your site so we can help connect students with you!  There are 19 questions that will take you 5-10 minutes to submit.  

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Question 1 of 19

What is the clinical instructor's name and credentials?  If you have more than one pelvic health clinician, please list here.  

Question 2 of 19

What type of clinician are you? 

A

Physical Therapist

B

Occupational Therapist

C

Physical Therapy Assistant

D

Occupational Therapy Assistant

E

Other (please specify in comments section)

Question 3 of 19

What advanced certifications do your clinicians hold?  For example, WCS, OCS, PRPC, BCB-PMD etc. 

Question 4 of 19

What is your primary practice site? 

A

Inpatient

B

Home Health

C

Outpatient

D

School Setting

E

Other (please specify in the comments section)

Question 5 of 19

What is the address of the primary practice site?  If you have more than 1 site, please specify and list them here. 

Question 6 of 19

Do you accept Physical Therapy Students? 

A

Yes

B

No

Question 7 of 19

Which type of students do you accept?  

(Select all that apply)
A

Physical Therapy

B

Occupational Therapy

C

Physical Therapy Assistant

D

Occupational Therapy Assistant

Question 8 of 19

Do you require any pelvic health training curriculum to be completed by students before their rotations with you? 

(Select all that apply)
A

We have no pre-requisites

B

Level 1 is required

C

Level 1 and Level 2 are required

D

Other (please specify in comments section)

Question 9 of 19

Do you accept students at any point in their scholastic program? 

(Select all that apply)
A

We accept 1st year students

B

We accept 2nd year students

C

We accept 3rd year or Capstone students

Question 10 of 19

Do you accept students of any gender? 

A

Yes

B

No

Question 11 of 19

Do you accept students that are "differently abled"? 

A

Yes

B

No

Question 12 of 19

Do you offer a student stipend?  If yes, please specify. 

Question 13 of 19

Please list the name and contact information for your student clinical site coordinator: 

Question 14 of 19

What is your website address where people can learn more about you and/or your company? 

Question 15 of 19

What are your social media account names where people can learn more about you and/or your clinic? 

Question 16 of 19

What patient types do you accept? 

(Select all that apply)
A

Pelvic pain

B

Pregnancy and postpartum

C

Bowel incontinence

D

Constipation

E

Orthopedics

F

Pediatric pelvic health

G

Transgender pelvic health

H

Bladder incontinence

I

Male pelvic health

J

Sexual dysfunction

Question 17 of 19

Are you a myPFM pro member? 

A

Yes

B

Not yet but I'd like more info

C

I'm not interested at this time

Question 18 of 19

If you are a myPFM Pro Member, please provide your name and email address associated with your membership

Question 19 of 19

myPFM Pro Members: Please upload your logo or headshot

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