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Leaps and Bounds - Pediatric Rehabilitation Center
 
   
 
 
 
 
 
 
 

























 

If you are interested in having your child attend an intensive exercise program at our facility, please contact us directly or follow the application process listed below.

  1. Completely fill out and return to us the Member Health Information Form. It is important to be as thorough as possible when filling out these forms. It will give us a better understanding of your child’s needs
  2. Upon approval for the intensive exercise program, you will need to submit a written report regarding recent hip x-rays (within last six months), specifically A/P view of your child’s hips to rule out any possible hip subluxation or dislocation .
  3. Once all information has been received, you will be contacted and a time will be scheduled for your child to attend our center.
  4. In order to secure a reservation at our clinic, we must receive a deposit in the amount of $1000.00 prior to your child’s scheduled session and the remainder of the balance is due when your child attends.
Medical Forms

Allergy Questionnaire   Word doc   pdf
Consent for Participation/ Informed Consent Waiver Word doc pdf
Medical Information Sheet Word doc pdf
Photograph & Video Consent & Release Form Word doc pdf
Release & Assignment Word doc pdf
Referral for Physical Therapy Word doc pdf
Referral for Occupational Therapy Word doc pdf

 

Copyright © 2005
Leaps and Bounds
Physical Therapy and