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New Client Consent
Please complete all sections to best of your ability
*
Indicates required field
Name of person receiving therapies
*
First
Last
If child, one legal guardian who will be present at sessions on average
*
First
Last
[object Object]
Type of session
*
In Home
Aquatic Therapy
Other
If Other please specify:
*
Adult session or child
*
Adult
Child (0 - 18)
If receiving Aquatic Therapy, has a doctor ever told you or your child that they should not be in a pool or swim?
*
No
Yes
Unsure
Do you have any reason to believe that you or your child should not participate in pool activities?
*
No
Yes
Unsure
I consent to myself or my child participating in Recreational or Aquatic Therapy:
*
Yes
No
I consent to my photo or my child's photo being taken while receiving Recreation Therapy. This is not a requirement but an option.
*
Yes
No
I consent to my photo or my child's photo being utilized for marketing or social media. This is not a requirement but an option.
*
Yes
No
Digital Signature: Please type your name below as a representation that all above information is true to the best of your knowledge and your agreement to receiving Recreation or Aquatic Therapy for yourself or your child:
*
First
Last
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Home
Services
Individual and Family
Groups and Programming
Consultation
What IS Recreation Therapy
Bio
Contact
