Physical Therapy Services – Intensive Therapeutics

At Intensive Therapeutics, we provide individual physical therapy evaluations and treatment. We work with our qualified partners from Next Step Pediatric Therapy.

Program Registration Form

Privacy is very important to us. No information sent to Intensive Therapeutics will in any way be distributed or shared without your acknowledgement and consent.

Instructions to complete registration forms:

Complete the Contact/Medical Information form below and click the send button.
Print out the following two forms:
a. Consent to Attend form
b. Video Permission form
Complete and sign these 2 forms and mail them to the specific site:
FOR FANWOOD:
Intensive Therapeutics, Inc.
274 South Avenue
Fanwood, NJ 07023

OR FOR WEST CALDWELL:
Intensive Therapeutics
31 Fairfield Avenue
West Caldwell, NJ 07006

Both forms must be completed, signed and the originals received at least one month before the start date of camp.

If you are human, leave this field blank.

Desired Starting Date

Name of Program

Registration Information

Child's Name *

First

Last *

Last

Date of Birth

Age

Gender

Parent's Name *

First

Last *

Last

Home Phone

Cell Phone

Phone Back Up

Email *

Address *

Address Line 2

City *

State *

Postal Code *

Country

Medical Information

Is your child on medications? *

Yes

Types of medications

Does your child have allergies? *

Yes

Please list allergies

Any other pertinent information?

Family Goals

What are one or two realistic / functional goals you would like to see your son / daughter achieve during this program?

History

Please describe briefly past attempts of participation in sports and current status

Consent Forms

Please upload completed Informed Consent and Video/Photo Permission forms here.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

Please confirm below: