application for program page

Participant Application

Basic Information:

First Name

Last Name

Date (mm/dd/yyyy)

Gender

DOB (mm/dd/yyyy)

Age (must be at least 18)

Phone

Please Choose All That Apply: If none apply, please contact us separately before completing this application and find out if you still can qualify for our program.

Veteran / Active-Duty Military / Reserves

If Yes, Which Branch of the Military

First Responder

If Yes, Which Department or Agency

Other

Emergency Contact Information: Provide at least one

Primary Contact

First Name

Last Name

Phone

Relationship

Secondary Contact (optional)

First Name

Last Name

Phone

Relationship

Medical Information:

Primary Care Doctor

Preferred Medical Facility

Primary Issue (diagnosed or not)

Secondary Issue if applicable

Current Medications

Alleregies, Asthma, Skin Sensitivites etc

Limitations

other medical conditions

Alcohol Use

If Yes, How Often

Non-Perscription Drug Use

If Yes, How Often

Personal Goals / Program Expectations

Current or Past Therapy Experiences

Schedule Availability: Check All That Apply

Mornings

Tuesdays 8:00 am to 11:00 am

Thursdays 8:00 am to 11:00 am

Aftenoons

Tuesdays 3:00 pm to 6:00 pm

Thursdays 3:00 pm to 6:00 pm

Ahava is Closed from July - August due to Arizona Summer Heat

How Did You Hear About Ahava?

Participant Appliation

Ahava

Therapy and Wellness Center

Participant Application

Basic Information:

Please Choose All That Apply: If none apply, please contact us separately before completing this application and find out if you still can qualify for our program.

Emergency Contact Information: Provide at least one

Primary Contact

Secondary Contact (optional)

Medical Information:

Schedule Availability: Check All That Apply

Ahava is Closed from July - August due to Arizona Summer Heat

How Did You Hear About Ahava?

Meet Our Partners and Sponsors

ahava.therapy.wellness@ahavatherapyheals.com