Summer 2020
June 8 - August 28

Please Complete Each Section Below

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* 1. Child's Full Name (First & Last)

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* 2. Email and Phone Number for Primary Caregiver

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* 3. Parent/Gurdian Name(s)

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* 4. Do you have a preference for location (understanding we may not be able to accommodate preference)?

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* 5.
Morning Availability (7:00-12:30)
Select ALL available times for each day of the week

  7:00-8:00 8:00-9:00 9:00-10:00 10:00-11:00 11:00-12:30 Unavailable
Monday
Tuesday
Wednesday
Thursday
Friday

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* 6.
Afternoon Availability (12:30-3:30)
Select ALL available times for each day of the week

  12:30-1:30 1:30-2:30 2:30-3:30 Unavailable
Monday
Tuesday
Wednesday
Thursday
Friday

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* 7.
Evening Availability (3:30 & Later)
Select ALL available times for each day of the week
Latest appointment start time is 5:00 pm

  3:30-4:30 4:30-5:00 Unavailable
Monday
Tuesday
Wednesday
Thursday
Friday

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* 8.
***FOR POOL PATIENTS ONLY***
(only complete this section if you have discussed pool treatment with your therapist)

Please note your availability for the following days/times for the service you will be receiving (understanding that if you are not available during these times you may not receive pool services this summer)

  Yes, we are available No, we are not available
Tuesday PT (2:30 or later)
Wednesday PT (am only)
Wednesday OT (am only)

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