PPT Aquatic Therapy Questionnaire
To Be Completed by Parent/Caregiver, one form for each child.
Aquatic Therapy is offered on Friday afternoons only. 
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2023 Aquatic Therapy Session Dates

Spring A January 6-March 17th

Spring B March 24th-May 26th

Summer June 2-August 4th

Fall A August 11-October 13

Fall B October 20-December 29

Email address *
Phone number
 *
Child's First Name
 *
Child's Last Name
 *
Child's Date of Birth
 *
MM
/
DD
/
YYYY
Parent/caregiver's name
 *
Parent/Caregiver's Phone Number *
Is your child a current patient at Progressive Pediatric Therapy?
 *
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/  Title
An active Plan of care is required to attend Aquatic Therapy.
Has your child received AQUATIC (POOL) therapy with PPT in the past?
 *
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.)
 *
Required
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. 
 *
Required
I understand that a $60 registration fee must be received before my child will be scheduled for weekly aquatic therapy.
 *
Required
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.
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