PPT Aquatic Therapy Questionnaire

To Be Completed by Parent/Caregiver, one form for each child.

Aquatic Therapy is offered on Friday afternoons only. Rolling sessions throughout the year.

Email *

Phone *

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Parent/Caregiver's Name *

Is your child a current patient at Progressive Pediatric Therapy? *

Yes

If you are a new patient at PPT, please fill out new patient forms on our website at: https://www.ppt4kids.com/new-patients/new-patient-forms/
An Active Plan of care is required to attend Aquatic Therapy.

Has your child received AQUATIC (POOL) therapy with PPT in the past? *

Yes

Please select which therapies you would like your child to receive in the pool. (Child must have an active plan of care for each therapy type.) *

Physical Therapy

Occupational Therapy

Speech Therapy

Is your child currently receiving any therapy somewhere else? *

Physical Therapy

Occupational Therapy

Speech Therapy

Not Applicable to Me

Are you planning on continuing therapy listed above somewhere else? *

Physical Therapy

Occupational Therapy

Speech Therapy

Not Applicable to me

I understand that this form will be utilized to alert the aquatic therapy staff of my interest. This is NOT the official registration form. An aquatic therapist will reach out to me regarding next steps and to send the registration form, should there be availability.

I understand that a $60 registration fee must be received before my child will be scheduled for weekly aquatic therapy.

Thank you for your interest in the Summer Aquatic Therapy session at PPT! Our Aquatic Lead therapist will contact you soon! Leave additional comments or questions below.