Professional Name(Required) First Last DOB_af_date MM slash DD slash YYYY Applicant Name(Required) First Last Other Info Social Worker Social Worker Physician Physician PT/OT PT/OT Counselor Counselor Nurse Practitioner Nurse Practitioner Other Other Applicant Disabilities Temp No Temporary No Temp Yes Temporary Yes Temp Disability Date Motor Wheelchair Motor Wheelchair Walker Walker Wheelchair Wheelchair Crutches Crutches Service Animal Service Animal Cane Cane Leg Braces Leg Braces Power Scooter Power Scooter Other Other Blind Yes Blind Yes Blind No Blind No Cognitive Yes Cognitive Yes Cognitive No Cognitive No Exceed 400 lbs Yes Exceed 400 lbs Yes Give Address No Can Give Address No Give Address Yes Can Give Address Yes Give Address Sometimes Can Give Address Sometimes Landmark Yes Can Give Landmark Yes Landmark Sometimes Can Give Landmark Sometimes Landmark No Can Give Landmark No Change Yes Ok With Change Yes Change No Ok With Change No Change Sometimes Ok With Change Sometimes Follow Diections Yes Can Follow Directions Yes Follow Directions No Can Follow Directions No Follow Directions Sometimes Can Follow Directions Sometimes Explain Responses Your Name Title/Position License or ID number Name Of Organization Office Address APT # State City Zip Code Office Phone Todays Date_af_date Signature
