Aquatic Therapy Waitlist

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Please fill out this form to be added to our aquatic therapy waitlist. We will have someone from our office contact you soon. Thank you!

Note: We are currently only offering OT and PT in the pool. Your child needs to already be receiving OT or PT on land at Milestone to participate in the pool.

Name of Child (first and last) *

Name of Parent, Caregiver or Guardian (first and last) *

Email Address *

Phone Number *

Are you currently being seen at Milestone for Occupational or Physical Therapy? *

Yes

No (I am sorry. You cannot be seen at this time without an active status in OT and/or PT)

What service are you requesting? *

Aquatic Occupational Therapy

Aquatic Physical Therapy

Required

Please list your child's therapists below. *

Submit

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