Win an Intensive Therapy Session

1. Your First and Last Name *

2. Address 1 *

3. Address 2

4. City *

5. State *

6. Country

7. Zip Code *

8. Home Phone

9. Mobile Phone

10. Email Address *

11. Child's First and Last Name *

12. Child's Gender *

Female

Male

13. Child's Diagnosis *

14. Child's Date of Birth *

15. Child's Insurance(s) *

16. Does your child have hip dislocation? *

Yes

No

17. If you answered "Yes" to question #16 , please state if right, left or both hips are involved and degrees of dislocation.

18. Does your child have scoliosis? *

Yes

No

19. If you answered "Yes" to question #18, please state the degrees of scoliosis

20. Does your child have seizures? *

Yes

No

21. If you answered "Yes" to question #20, are the seizures controlled with medication?

Yes

No

22. Is your child diabetic?

Yes

No

23. Does your child have any cardiac or metabolic disorder? *

Yes

No

24. If you answered "Yes" to question #23, please describe:

25. What types of therapy is your child currently receiving (private and school-based PT, OT and ST, Hippotherapy, Aquatic Therapy, etc)? **Please state how many times per week and minutes per session for each therapy. *

26. Please describe what your child can and cannot do, type of assistive devices he/she is using, your concerns, and why you believe your child would benefit from intensive physical therapy. *

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

28. Are you interested in our intensive therapy program even if your child does not win?

Yes

No

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