Adult OT Request for Service Form

Service Requested

Post-COVID Assessment & Therapy

Mental Health Assessment and Direct Therapy

Functional Assessment (Home-based)

Home Modifications Assessment

Mobility Equipment Assessment and Prescription

BrainFX 360 Cognitive Assessment

Med-Legal Cost of Future Care Assessment

Physical Functional Capacity Evaluation

Cognitive Functional Capactiy Evaluation

Home Office Ergonomics Assessment

Workplace Office Ergonomics Assessment

Workplace Disability Accommodation Assessment

Physical / Cognitive Job Demands Analysis

I want to subscribe to this inclusive community to receive news and funding opportunities related to the service I am requesting.

I accept the $50 no show fee for any missed appointments without prior notification of cancellation.

As a new client, I understand that I must complete the Credit Card Authorization form in addition to this request for service form.

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