Bolton Neuro Voices (BNV) Physiotherapist - led Hydrotherapy Course Application Form

Please complete the following form to enable us to ensure your safety and participation in our BNV Physiotherapist-led Hydrotherapy Course. Upon submitting this form, you will receive an immediate confirmation message. A Physiotherapist will then call you to discuss your application further and at this time will answer any questions you may have. If you require any assistance changing you MUST bring your own carer for support. If your carer will be getting in the pool with you, they will need to provide some information about themselves and their health. If you experience any difficulty in completing this form, please contact a member of our Support Team on 0161 764 3799. If not immediately available, they will call you back.
  • Part One: About You

    Please select as appropriate
  • Please indicate your 3 priorities from the following list;
  • Who is your emergency contact?
  • Part Two: About your health

  • It is important that we understand all of your needs and any health risks from your participation. Please tick if you have any of the following medical problems. Having one of these conditions will not necessarily exclude you, but we do need to know about it. If you are unsure of your answers, please discuss participating in hydrotherapy with your GP.
  • Part Three: About Your Mobility

  • Part Four: Access and assistance

  • Part Five: About Your Water Confidence

  • If you require assistance whilst in the water from your own carer, please give your carer’s details below. Ensuring their safety is also important and we will contact them direct.
  • Part Six: Follow-up appointments

  • The Physiotherapist will review your application form and will be following up with a telephone call. These calls will take place on Weds 2nd February 2022 between 9.30am and 4.30pm
  • If you would like someone else to complete your telephone assessment, please indicate below: