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Physical & Occupational Therapy
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Physical & Occupational Therapy
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Request form for Personal Trainers
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Name
Address 1
Address 2
City
State
Zip
Country
Phone
TTY
Toll Free
Fax
URL
Email
General Description
Months of Experience
Do you train at fitness center?
Yes
No
Do you train at clients home?
Yes
No
Do you train at trainers home?
Yes
No
Other public facility (park district, YMCA)?
Yes
No
Certifications?
Yes
No
ACSM certification (please specify which one)
ACE certification (please specify which one)
Other certification (please specify which one)
Occupational Therapist (OT)
Yes
No
Occupational Therapist Assistant
Yes
No
Physical Therapist (PT)
Yes
No
Physical Therapist Assistant
Yes
No
Registered Nurse with some coursework in exercise physiology or other related area
Yes
No
Degree in Kinesiology / Physical Education / Exercise
Yes
No
Specialization in Adapted Physical Education
Yes
No
Specialization in Therapeutic Recreation?
Yes
No
Other, please specify
Are children trained?
Yes
No
Are adolescent trained?
Yes
No
Are young Adults trained?
Yes
No
Are adults trained?
Yes
No
Are olderadults trained?
Yes
No
Are seniors trained?
Yes
No
Are all trained?
Yes
No
Train individuals with aids?
Yes
No
Trains individuals with alzheimer?
Yes
No
Train individuals with amputation?
Yes
No
Trains idividuals with arthritis?
Yes
No
Trains individuals with autism?
Yes
No
Trains individuals with cancer?
Yes
No
Trains individuals with cardiovascular?
Yes
No
Trains individuals with diabetes?
Yes
No
Trains individuals with emotional disturbance?
Yes
No
Trains individuals with epilepsy?
Yes
No
Trains individuals with fatigue?
Yes
No
Trains individuals with Fibromyalgia?
Yes
No
Trains individuals with frailty?
Yes
No
Trains individuals with headinjury?
Yes
No
Trains individuals with hearing impairment?
Yes
No
Trains individuals with intelleectual?
Yes
No
Trains individuals with learning disabilities?
Yes
No
Trains individuals with low back pain?
Yes
No
Trains individuals with multiple disabilities?
Yes
No
Trains individuals with multiple sclerosis?
Yes
No
Trains individuals with multipledis?
Yes
No
Trains individuals with obesity?
Yes
No
Trains individuals with other orthopedic impairment?
Yes
No
Trains individuals with osteoporosis?
Yes
No
Trains individuals with parkinsons disease?
Yes
No
Trains individuals with post-polio disease?
Yes
No
Trains individuals with pulmonary disease?
Yes
No
Trains individuals with speech/language impairment?
Yes
No
Trains individuals with spinalcord?
Yes
No
Trains individuals with stroke/brain?
Yes
No
Trains individuals with visual impariment?
Yes
No
Other, please list
Adaptive equipment
Do you offer any sliding/adjusted fee scales or discounts for your clients with disabilities?
Is your program/facility accessible by public transportation?
Do you provide transportation to your training facilities?
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