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:
DOB:
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.
