Summer Aquatic Therapy Intensive

Parent Name *

Child Name *

Child's Age *

Primary Diagnosis *

GMFCS Level (if applicable)

Main goal for intensive *

Please check boxes that DO apply to your child:

Independent Rolling

Independent Sitting

Independent Standing

Independent Walking

Sitting (assisted)

Standing (assisted)

Walking (assisted)

Wheelchair user

Assistive device (walker, forearm crutches, etc)

Dependent on caregiver for most transfers and activities of daily living

Preferred Intensive Schedule *

1 hour/day x 1 week

1 hour/day x 2 weeks