Application for dolphin therapy in Berdyansk - NEMO

Child’s information:

The child’s full name *

Date of birth *

Child's Height (sm)

Weight of child (kg)

Main/concomitant diagnosis *

Epileptic seizures, convulsive readiness Yes No

Cancer Yes No

Contact information:

Parents’ full names *

Contact phone *

Email: *

Your address

Convenient dates: from

till

Requested services: (tick off where appropriate)

Dolphin therapy sessions

Desired number of sessions:

Tell us how you learned about us:

Additional information

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