Physical Therapist/Occupational

Therapist/Technical Assistance

Form Instructions: This is a fillable PDF form and can be filled out electronically utilizing Adobe Reader/Acrobat.

This form must be filled out completely. Incomplete forms may be returned to the Requester. Return this form to MRETeam@dbhds.virginia.gov.

Forms will ONLY be accepted by email unless prior arrangements have been made with MRE Management.

CLIENT INFORMATION

Indicate individual’s type of residence: {{Residence}}

Name of Individual: {{Name}}
Street Address: {{Street Address}}		Phone: {{Number}}
City/Town: {{City}}	Zip Code: {{Zip}}	Email: {{Email}}

REQUEST TYPE

Request Type (Please select all that apply):
{{Request}}

MEDICAL HISTORY

Diagnosis:

Any recent changes in Health Status? (stroke, hospitalizations, surgeries, etc.): {{Changes}}

If so, what kind?

Is the individual Ambulatory or Non-Ambulatory?: {{Ambornon}}

Ambulatory Foot Orthotics? {{Foot}}

Hand Splints? {{Splints}}

Wheelchair Type: {{WcType}}

Wheelchair Brand: {{WcBrand}}

Does the Wheelchair Tilt? {{WcTilt}}

Wheelchair Ramp? {{WcRamp}}

Stairs? {{Stairs}}

Stair or Chair lift? {{SorCLift}}

Patient Lift? {{PLift}}

If yes, is the lift electric or manual? {{EorM}}

Does the individual ride in an Accessible vehicle while seated in a wheelchair? {{Ride}}

Diagnosis:
{{Diagnosis}}
Any recent changes in Health Status? (stroke, hospitalizations, surgeries, etc.): {{Changes}}
If so, what kind?
{{Kind}}
Is the individual Ambulatory or Non-Ambulatory?: {{Ambornon}}
Ambulatory Foot Orthotics? {{Foot}}	Hand Splints? {{Splints}}
Wheelchair Type: {{WcType}}	Wheelchair Brand: {{WcBrand}}
Does the Wheelchair Tilt? {{WcTilt}}	Wheelchair Ramp? {{WcRamp}}
Stairs? {{Stairs}}	Stair or Chair lift? {{SorCLift}}
Patient Lift? {{PLift}}	If yes, is the lift electric or manual? {{EorM}}
Does the individual ride in an Accessible vehicle while seated in a wheelchair? {{Ride}}