Therapist's Name *

First Name

Last Name

Therapist's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Therapist's Phone *

(###)

###

####

Child's Name *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Parent / Guardian Name *

First Name

Last Name

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Phone *

(###)

###

####

Parent/Legal Guardian HAT Project consent form submitted *

Yes

Accesss Options - UE Preference: *

Right

Left

N/A

Accesss Options - LE Preference: *

Right

Left

N/A

Accesss Options: *

Head

Foot

Joystick

Switches

N/A

Home Setting: *

Space to store / Accessibility

Space to operate

Capability to transport

Motorized Wheel Chair: *

Currently operates a motorized wheel chair

Currently cannot qualify for a motorized wheel chair

A motorized wheel chair is not a goal or need