Physical Therapy & PTA Client Intake Form

Practice Information

Practice / Organization Name *

Owner / Primary Contact *

Email *

Phone Number *

Practice Address *

Website

Practice Profile

Number of Treatment Rooms / Gyms *

Practice size *

Hours of Operations *

EMR / Scheduling Software *

Patient Volume (approx. patients/week per clinician) *

Under 30

30–50

51–75

75+

Staffing Needs

Role(s) Needed (select all that apply) *

Type of Hire (select all that apply) *

Permanent / Direct Hire

Contract / Travel (13-week)

Per-Diem / Temp

Contract-to-Hire

Number of Open Positions *

Desired Start Date *

Assignment Length (if contract/travel) *

Work Schedule Preference *

Work Schedule (select all that apply) *

Full-Time (40 hrs)

Part-Time

PRN / As Needed

Flexible / Rotating

Requirements & Preferences

Years of Experience Preferred *

New Grad welcome

1–2 years

3–5 years

5+ years

EMR Proficiency Required?

Yes — specify below

No — willing to train

If yes, list required systems: *

Compensation Range (optional — helps expedite matching)

Pay Rate (contract/travel, per hour)

$

Salary Range (permanent hire)

$

Housing / Stipend Offered for Travel Positions?

Yes — housing provided

Yes — stipend only

N/A (not a travel role)

Cultural / Team Fit Notes: *

Compliance & Onboarding

Background Check Required?

Yes

No

Already handled by our credentialing team

Drug Screening Required?

Yes

No

Credentialing / Onboarding Handled By

Our in-house HR / Credentialing team

Third-party credentialing vendor

We request CoreEthos assistance

Does your facility require proof of specific immunizations or health clearances?

Yes — see notes below

No

e.g., COVID-19 vaccination, TB test, flu shot, Hep B

Authorization & Next Steps

I confirm that the information above is accurate and I authorize CoreEthos Group to match my practice with

qualified PT/PTA professionals based on the stated criteria. I understand that CoreEthos Group will contact me to

confirm details before initiating candidate outreach.

Authorized Signature *

Clear

Printed Name *

Date *

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