REFERRAL FORM
Rehabilitation Technology Associates
Fed ID 38-3163140

 

Print a PDF and mail or Fax

Mail: PO Box 540, Kinderhook, NY 12106
E-mail: Mail@retech2000.com
Fax: 518-758-8505
 
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:
 
Vehicle Modification Information:
  Please include in your referral to us any reports regarding client's assessment
for driving, vehicle information, inspections conducted, and transfer abilities.