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Occupational Therapy Application

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
Name*
MM slash DD slash YYYY
Address*
Does the applicant have a medical diagnosis? (i.e., Autism, Down Syndrome, Learning Disability, Dyslexia, Stroke/Aphasia, Parkinson’s, etc.)*
Has the applicant been a client at RRC in the past?*
Is the applicant currently receiving occupational therapy at another facility?*
Has the applicant received occuptational therapy at another facility in the past?*
Max. file size: 32 MB.
**If you do not have this you can get your doctor to fax this to us at 662.842.0941
Agreement*
Please Check Box above agreeing you understand

If you have any questions or concerns about our application please call us at 662.842.1891