Register for
Gold Coast – July 27 – August 14 (waitlist only)

Patient Name*

Parent / Guardian Name*

Phone Number

Email*

Patient Intake Paperwork Completed?*

-None-YesNo

Session Duration*

-None-1 Hour/Day2 Hours/Day3 Hours/Day4 Hours/Day5 Hours/Day6 Hours/Day

Would you like a break in the session?*

-None-YesNo

Break Length*

-None-30 min lunch (12-12:30)1 hour2-3 hours4 hours

Type of Therapy*

Neurosuit TherapyCuevas MEDEK ExercisePhysical TherapyOccupational TherapySpiderCage TherapyFeeding TherapySpeech TherapyHyperbaric Oxygen TherapyTherapist Recommended ProgramTrexo PlusIntensive Feeding Program (2-3 hrs)Dynamic Movement Intervention

Which preference is most important to you?*

-None-Start TimeTherapy Team

Which start times will work for you?*

8:00am9:00am10:00am11:00am12:30pm

Therapist 1

Therapist 2

Therapist 3

Therapist 4

Would you like to stay at the NAPA apartment?*

-None-YesNo

Additional Requests