2025 Intensive Sign Up

This form should be filled out if you are interested in a PT or OT intensive at Move Pediatric Therapy. Move Pediatric Therapy is located in Charlotte, North Carolina, USA. Please read this information carefully before filling out the form. Filling out this form does not guarantee that you will get an intensive spot in 2025 but we will do everything we can to see as many children as possible. Priority will be given to those wishing to book both an OT and a PT intensive. The intensives do not need to be completed on the same week. Pricing for our 2025 intensives are as follows PT 5 total hours $1000, PT 10 total hours $2000, OT 5 total hours $800, OT 10 total hours $1600. Three week intensives are also available by request. Deposits are due 3 weeks after you receive your confirmation email. Deposits are non refundable but if you must cancel and there is space later in the year your deposit can be used towards another intensive session (this will be assessed on a case by case basis). Thank you for your interest in Move Pediatric Therapy's intensive program! *

I have read and understand the information above

Child's Name *

First

Last

Child's Date of Birth *

Child's Primary Diagnosis *

PT case space

Parent/Guardian Name(s) *

Parent/Guardian Email *

Parent/Guardian Phone Number *

Interested In (click all that apply) *

1 week PT intensive
1 week OT intensive
2 week PT intensive
2 week OT intensive
3 week PT intensive
3 week OT intensive

Duration of Therapy (click all that apply) *

1 hour of PT per day
1 hour of OT per day
2 hours of PT per day
2 hours of OT per day

If you want 2 hours of total therapy per day (OT or PT) please pick your preference (preferences are not guaranteed)

I prefer 2 hours of therapy back to back
Please split up the sessions so that my child has a break in-between
I don’t have a preference

Preferred Week(s) of the Intensive (may list multiple options, please list your first preference at the top) If you do not have a specific week(s) in mind please indicate your preferred month for an intensive *

Preferred Time of Day (timing not guaranteed)

am
pm
I don’t have a preference

Is there anything else you'd like us to know about your child?

I understand the following statements (all boxes must be checked to be considered for a 2025 intensive spot)

submitting this form does not guarantee that I will receive an intensive spot for 2025
a 50% deposit is due within 3 weeks of receiving a confirmation email from Move Pediatric Therapy
if my preferred week is already taken I will be offered an intensive spot on a different week
priority will be given to those wanting to schedule PT and OT intensives for ease of scheduling

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