2016 Boca Raton Fall Aquatic Descriptions. Due: January 6th, 2016 with $35.00 registration fee. Phone: Fax:

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1 2016 Boca Raton Fall Aquatic Descriptions Due: January 6th, 2016 with $35.00 registration fee Phone: Fax: Aquatic Therapy Exercise in the water can be used to strengthen weak muscles, relax tight muscles, and improve body awareness, coordination, and control of movement for functional tasks. Using the physical properties of the water, our physical and occupational therapists work to improve independent function. Objectives Increase range of motion. Increase strength using water and adaptive equipment for resistive exercise. Improve muscle control and endurance for functional movements on land and in the water. Improve body awareness, sensory organization and coordination. Improve respiratory capacity. Children Who Will Benefit Infants and toddlers can begin with early work on trunk and head control, functional movements, even advanced gross motor skills in a buoyancy-supported, natural community environment. School-age children can use a new environment to increase motivation and keep strengthening during growth spurts. Adolescents work with the partial bodyweight support of water at varying depths to transition functional independence into land-based skills. All ages find the water can be calming and organizing environment that may help increase attention and functional interactions. Post-surgery, get weak limbs moving sooner and develop new patterns of movement for improved functional outcomes Time and Location Boca Raton Location Florida Swim School, 1082 S Rogers Cir, Boca Raton, FL January 12 th -May 3 rd Every Tuesday (16 weeks) 1 hour sessions from 2:30 till 5:00 PM NO Aquatic Therapy on Tuesday, March 22 nd,2016 Cost: Billed to insurance as therapy ($ pool fee) or Pay $1, without insurance which includes pool fee.

2 " Boca Raton Fall Aquatic Registration Form 2016 Due: January 6th, 2016 with $35.00 registration fee Phone: Fax: Please complete this form to register your child. Programs are filled in order in which registrations are received and might be filled prior to registration deadline. Participant s Name Age BirthDate _ Address City _ State Zip_ Legal Guardian s Name Phone_ AltPhone Referring Physician s Name Phone_ Participants Diagnosis

3 Aquatic Therapy Boca Raton Location Florida Swim School, 1082 S Rogers Cir, Boca Raton, FL January 12 th -May 3 rd Every Tuesday (16 weeks) 1 hour sessions from 2:30 till 5:00 PM NO Aquatic Therapy on Tuesday, March 22 nd,2016 Cost: Billed to insurance with pre-approval as therapy with copays/deductibles paid at time of service plus $ pool fee or Pay $1, without insurance which includes pool fee. If parent would like for us to verify insurance please specify which specialty will be seen in the pool. Occupational Therapy Physical Therapy Please check mark if you are privately paying or you would like for us to verify your insurance. We will need a prescription from your doctor and pre-approval must be obtained 3 weeks prior to start of session to use insurance for aquatic therapy. Private Pay ($1,200.00) Use Insurance plus $ pool fee and any deductible/ copays (if insurance does not cover family will be responsible) Please mark time choices as 1, 2, and 3 and we will do our best to accommodate your needs. Payment: 2:30pm 3:15pm 4pm 4:45pm 5:30pm 6:15pm Please check program payment method: Check Visa MC AMEX Credit Card Exp. Date Your credit card will be billed for pool fee and any copays/deductibles weekly. If private pay, please mark as so and all must be paid upfront. Insurance Company Insurance ID# Policy Holder Policy Holder DOB: Insurance Group # Please return your registration form, payment, or insurance card and prescription to:

4 Progressive Pediatric Therapy Boca Office West Palm Beach Office 5458 Town Center Rd., Suite Okeechobee Blvd, Suite 205 Boca Raton, FL West Palm Beach, FL Phone: Phone: Fax: Fax: Progressive Pediatric Therapy has the appropriate current prescription with my child s diagnosis on file. If not, please enclose with application. Yes No _ Is your child enrolled in individual therapy at Progressive Pediatric Therapy currently? Yes _ No_ If Yes, Discipline/Therapist: If no, please fill out new patient paperwork as we must perform any evaluations prior to beginning aquatic therapy and prior authorization must be obtained prior to start of the program. Payment and Cancellation/Refund Payment Options and Cancellation/Refund Policy If you would like to apply for a scholarship please let our front office know and we will give you the forms to fill out to request from Hope4Mobility. Registration Deadline is January 6th, 2016 in order for us to be able to set up our programs. Please fax, mail, or drop off at one of Progressive Pediatric Therapy Locations. All program dates, times, and locations are subject to change. Prior to being placed on a program roster, outstanding account balances must be settled with the billing department. Option 1 The cost for certain programs can be billed to your insurance. To exercise this option, please complete the insurance information on the registration form, and include a copy of your insurance card with your prescription and registration. There is also a $35.00 registration fee for all programs. Option 2 Payment must be made for specific program registering for and there is also a $35.00 registration fee for all programs. Cancellation/Refund Policy If withdrawing prior to the start of the program we reserve the right to charge the $35.00 registration fee. Cancellation must be made 3 weeks prior to start of program otherwise full payment is due. Please Note Check with your insurance company to make sure that your plan covers for physical, occupational, or speech therapy. Payment is ultimately the responsibility of the legal guardian. Attendance Policy It is Progressive Pediatric Therapies policy that all children receiving services attend at least 75% of their appointments in order to remain on the therapy schedule. Please commit to regular attendance in order to get the maximum benefit from therapy. I have read all the above and understand Progressive Pediatric Therapies policies:

5 Parent/Guardian Signature Date Medical Background/Information (FOR NEW FAMILIES ONLY): Does your child have a diagnosis/condition? Yes No If yes, please describe: Does your child have any physical limitations/restrictions? Yes No If yes, please describe: Does your child have a seizure disorder? Yes No If yes, please provide type and frequency: Does your child take any medications? If so please list all medications, dosage and time of day meds are given: Please describe your child s social and play skills: Please describe your child s sensory motor, gross and fine motor skills. Please note any safety concerns: Please describe your child s speech and language skills: Communication (Please send any communication system used with child) Nonverbal Fully Verbal Some Language Device Sign Language Picture Symbols Communication Board Please indicate how your child communicates his/her needs. (Example: points to things, becomes very loud when upset, says red or juice, etc.) Is your child independent in going to the bathroom, dressing and feeding? If not please describe level of assistance they are likely to need during the camp: List toys and activities your child likes. Examples: play-doh, books, animals, music, etc.