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 benefit by the services ReTech provides.

There are several submission methods provided. By filling in digital form below, your information is emailed to the ReTech office. If you prefer, you may print a PDF of this form, and fax or mail via USPS.

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

Fill in all fields in the form below and click on 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!