Central Coast Assistive Technology Center

of United Cerebral Palsy of San Luis Obispo

                                                                                                                                         

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Central Coast Assistive Technology Center  

 

CCATC Evaluation Referral Form
*Only residents of Ventura, Santa Barbara or San Luis Obispo Counties may use this form.

Please fill out this form, print it and fax the completed Referral Form, Authorization, and Release of Information to CCATC at 805-549-7423. Thank you.

Name:
SSN:
Ethnic:
D.O.B:
Home Address:
CITY STATE , ZIP
Work Address:
CITY STATE , ZIP

Home Phone:

Work Phone:

Diagnosis:

Consumer's Goals:

Referring Source Name, Organization & Phone Number:

 

Consumer is in need of evaluation in the following areas:

Home site Access Augmentative Communication
Worksite Access Mobility (not automobile)
School site Access Vision
Computer Access Hearing
Other:

Consumer needs specific evaluation in the following areas:

Home Entry  Computer Access
Bathroom Access Phone Access
Kitchen Access  Work Station Configuration
Manual Wheelchair Power Wheelchair
Consumer Lifts Wheelchair Positioning
Walker   
Hand/Arm Strength & Range of Motion
Work Access (other than computer/work station)
Other1:
Other2:
Other3:
Other4:
Other5:

Comments:

*Please send all pertinent medical reports and functional assessment information.

 

 

 

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