Rehabilitation Center Client Application Form

Client Contact Information

Name: *

First

Last

Date of Birth:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Telephone #:

Email:

Preferred mode of communication:

Emergency Contact information

Emergency Contact Name:

First

Last

Relationship:

Emergency Contact Address:

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Phone:

Emergency Contact Email:

Health Information

Please attach a copy of your insurance card (front and back) and a list of all medications.

Cause of vision loss:

Onset of vision loss:

If you have a legal blindness diagnosis, when was it diagnosed?

Name of Eye Doctor:

Eye doctor telephone number:

Name of primary care physician:

Primary care physician telephone number:

Name of health insurance company (required): *

Health insurance ID number (required): *

Are you your own guardian? (If no, please attach copy of guardianship decree.)

Are you your own guardian? (If no, please attach copy of guardianship decree.)

Yes
No

Please list all health diagnoses:

Please list any medications:

Please list any allergies:

Please list any dietary restrictions:

Please list any mobility aids you use:

Please list any vision aids you use:

Please list any medical assistive devices you use:

Tell Us About Yourself

Briefly describe your work experience:

Briefly describe any volunteer experience:

What hobbies or interests do you have?

What languages do you speak at home?

What level of education have you completed?

Briefly describe your current living arrangement, for example, alone, with spouse, with family, with significant other, other:

What are three goals you would set for yourself if admitted to the program?

Is there anything else you would like us to know?

Name as Signature: *

First

Last

Checking this box indicates an electronic signature *

Check to accept

Date: *