Step 2:  Physical Therapist Recommendation

The following form is to be filled out by the Physical Therapist of the applicant and emailed to harGIVES@hargrove-epc.com or you may submit the information online in the below.

Therapist's Name *
Therapist's Name
Therapist's Address *
Therapist's Address
Therapist's Phone *
Therapist's Phone
Child's Name *
Child's Name
Child's Date of Birth
Child's Date of Birth
Parent / Guardian Name *
Parent / Guardian Name
Child's Address *
Child's Address
Parent / Guardian Phone *
Parent / Guardian Phone
Parent/Legal Guardian HAT Project consent form submitted *
Please address head control and trunk control.
Total inches
Total inches
Total inches
Total inches
Total inches
Total inches
Total inches
Total inches
Accesss Options - UE Preference: *
Accesss Options - LE Preference: *
Accesss Options: *
Home Setting: *
Motorized Wheel Chair: *