Observation Request
Please fill out the form below to express your interest in observing one of our Speech, Physical, or Occupational Therapists. If under the age of 18, please complete with your Parent/Guardian.
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Current Education Level:
*
High School Student
Undergraduate College Student
Graduate Program Applicant
Other
What are you hoping to gain from this observation experience? (Choose all that apply)
*
Learn more about a potential career path
Fulfill a set number of observation hours required by my program
Work consistently with 1-2 therapists to gain a deeper understanding and potentially earn a letter of recommendation for program applications
Other
What disciplines are you interested in observing? (Choose all that apply)
*
PT
OT
ST
What population are you interested in observing? (Choose all that apply) *Please note that adult observation opportunities are limited and not guaranteed as we continue to build our caseload.
*
Primarily Pediatrics
Primarily Adults
A mix of both if available
Why are you interested in observing therapy at our clinic?
*
What types of diagnoses are you most interested in observing?
*
What are your career goals within the healthcare or therapy field?
*
We currently have a cap of 8 total hours available for observations. How many hours are you hoping to observe?
*
Preferred Observation Days & Available times between 8am-6pm:
*
Please read the following statements carefully. By checking the boxes and providing your signature below, you affirm that the information is true and agree to uphold these terms during your scheduled observations.
*
Signature agreeing to our terms and conditions as noted above (Parent/Guardian if under 18)
*
Parent/Guardian Name if under 18
First Name
Last Name
Submit
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