Driver information referral submission form

ReTech's Digital Referral Form

You are welcomed and encouraged to submit information about organizations or persons in New York, Ohio and Indiana, who may need or benefit from ReTech services.

Please choose one of the submission methods below:
●	Complete the digital form below. Clicking the "Send" button will email your responses to ReTech headquarters.
●	You may print a PDF of this form and either fax or send via US Mail.

Mail: PO Box 540 ▪ Kinderhook, NY ▪ 12106 ▪ Fax: 518-758-8505

Complete the form below and click the "Send" button at the bottom.

Date:
Counselor / Physician:
Telephone:
Address:
City:
State:	Zip:

Counselor / Physician e-mail:
Fax:

Consumer:
Date of Birth:
County:
Address:
City:
State:	Zip:
Home Telephone:
Work Telephone:
Consumer e-mail:
Client Disability:
Date of Onset:
Impairment:
Type any vehicle modification Information you may have, below.

Below, please include any reports regarding client's assessment for driving, vehicle information, inspections conducted, and transfer abilities.

Thank you for using this digital form!