Name (parent/guardian) *

Yes, I'd like to have a home modification evaluation. - NO waitlist for this service currently. WE ARE NO LONGER ACCEPTING ANYMORE WAITLIST PARTICPANTS FOR AQUATIC THERAPY/OUTPAITENT OT FOR APPOINTMENTS AFTER 4:00PM. PLEASE CHECK BACK 11/1/2025 FOR ANY UPDATES IN THIS TIME FRAME. * If you have daytime availability for aquatic therapy/outpatient i.e. before 4:00PM please add yourself or your family member to the waitlist. We are now accepting waitlist participants with daytime openings. * We are actively hiring and training the providers with the right fit in order to open the waitlist again.

First Name

Last Name

Child Name First/Last

First Name

Last Name

Child Date of Birth

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DD

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Service of Interest?

Please choose all that apply

Aquatic Therapy/Learn-to-Swim

Outpatient OT Services

Home Modification Evalution

Help with Medicaid Wavier Services & Resource Education

Other