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Reservation

Online Reservation

Family information

Surname *
Name of the mother : *
Name of the father :
Phone *
Email *
Address
Street AddressApt, Suite, Bldg. (optional)ŞehirEyalet / İl / BölgePosta / posta koduÜlke

Informationen about the child

Name of the patient :
Date of birth :
Name of the disease
Age :
Size :
Weight :

Does the child need help at the fields mentioned below?

Toilet :
YesNo
Sitting :
YesNo
Eating :
YesNo
Standing :
YesNo
Getting Dressed :
YesNo
Locomotion :
YesNoOption 3

Please answer the questions given below.

Does the child need special devices?(If so, please provide more detailed information)
How would the child react to "No, you cannot do it/get it now!"
Can the child stretch his/her legs?
Can the child swallow?
Is the child under medical treatment? (If so, which medecines, when and in which intervals does the medication take place, for what purpose and how. Please provide detailed information )
Strengths and weaknesses of the child?
Is the child afraid of big animals and deep water?
Can the child swim?
Can the child use swimming goggles?
Does the child allow foreign persons to touch and hug him/her?
Does the child suffer from visual disorder? ( If so, please provide detailed information.)
Can the child hear?
Can the child follow simple instructions?
Which goals and expectations do you have concerning your child?
What do you know about the dolphin therapy?
How did you become aware of our activities?
Which therapy types were tried before and what were the results?
Does the child have brothers and sisters (if so, please tell us their sex, age and expectations)

Please determine the frequency that fits best. %0 never - %25 sometimes - %50 often - %75 quite often - %100 always

Can the child move his head in a controlled way?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she behave in a way, which could inflict harm upon himself/herself? (biting, scratching,beating)
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she have choleric outbursts?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Can the child move his head in a controlled way?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does your child behave in an aggressive way?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Can he/she create sounds?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Can he/she create words and/or sentences?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she have an allergy?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she use the sign language?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does the child use another form of communication?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
If so, please describe those communication form(s)?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she answer, if called by his/her name?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Can he/she follow instructions?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Does he/she recognize changes in the environment?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Is he/she hypersensitive against sunbeams and/or heat?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
Can he/she use a language for communication?
%0 Never%25 Sometimes%50 Often%75 Quite Often%100 Always
If allergies exist, please name them.
Where will you stay in Antalya?
Please determine the required period for the therapy, and add, if necessary, any kind of further information.

Verification

Please enter any two digitsExample: 12
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