Win an Intensive Therapy Session

Please Complete the Entire Contact Information Form and Submit for a Chance to Win a Free Intensive Therapy Session

This form is to be used by parents/caregivers of children with disabilities to apply for a chance to Win a Specialized 3 week Intensive Therapy Session.

If you are a business attempting to contact us, please use the email or phone number provided on our Contact Us page.

First and Last Name *

Address 1 *

Address 2

City *

State *

Country *

Zip Code *

Home Phone

Mobile Phone

Email Address *

Child's First and Last Name *

Child's Gender *

Female

Male

Child's Diagnosis *

Child's Birthday *

Please provide a brief description of why you would believe your child would benefit from intensive physical therapy. *

What is your functional goal for your child should he/she participate in our intensive therapy? *

Please Complete the Entire Contact Information Form and Submit for a Chance to Win a Free Intensive Therapy Session

Ability Plus Therapy

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