20 Free Treatments - Over $1200 Value -
Amy Hicks is not just a registered massage therapist; she is also a registered kinesiologist and osteopathic student.

She has a particular interest in working with the special needs community and takes a scientific and caring hands-on approach to healing.

Amy is dedicated to helping children with autism reach their full potential. She currently offer proprioceptive and vestibular massage for these children and is very excited to be adding QST massage to her practice in the near future.

She is taking QST training in October 2017 and is offering 20 free treatments (between Oct. and March 2017) to a child with autism as she completes her QST certification.

Please Complete the Survey below to Apply
Contact Information
Parent/Gurdian Name *
Your answer
Child Name *
Your answer
Child Date of Birth *
Email Address *
Your answer
Daytime Phone Number *
Your answer
Evening/Weekend Phone Number *
Your answer
Home Mailing Address *
Your answer
Your Child and QST massage
Is your child under six years of age? *
Does your child have an educational or medical diagnosis of autism? *
Is your child on little or no psychotropic medications. These medications can affect the nervous system and thereby the results of QST massage. *
Will your child be on any intensive medical interventions during the program? *
Will your child be on any intensive behavioural interventions during the program? *
Does your child have any additional neurological conditions or disabilities, e.g., uncontrolled seizures, cerebral palsy, etc.? *
I am able to consistently bring my child to Bedford, NS for up to two treatments a week between Oct. and March 2017. *
I am comfortable having my child video-taped for educational purposes, these videos will be destroyed at parent request at the end of the treatment period. *
I am willing to participate in parent training and at home massage (15 minutes a day). *
I am willing to participate in an exit interview, reviewing my experience with QST massage and my child. *
Please tell us more about your child and the benefits you hope to see from QST massage *
Your answer
Commitment to attending treatment sessions is extremely important. Please describe how attending treatments, or rescheduled treatments if the child is sick, will fit easily into your routine. *
Your answer
Thank you for Completing your Application!
You will receive an email by mid September if your child has been selected as a top candidate. Top candidates parent's will have a short phone interview before the final candidate is selected.
If you have any further questions regarding your application or are interested in pursuing proprioceptive and vestibular massage therapy treatments for your child please email: amy@acornabilityclinic.com
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service