Legacy Project Application
Email address *
CLIENT INFORMATION
First & Last Name *
Cell Phone *
Alternative Phone Number
Street Address *
City, State & Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Height *
Weight *
Medical Diagnosis *
If you noted 'other' above, please specify diagnosis here:
Date of Injury or Onset *
MM
/
DD
/
YYYY
If spinal cord injury, what is your level of injury?
Do you have any of the following (check all that apply): *
Required
Type of wheelchair, if applicable: *
List assistive devices you use in your everyday life, if applicable:
EMERGENCY CONTACT
Contact Person (First & Last Name) *
Contact Phone Number *
Relationship to Client *
GOALS & QUALITY OF LIFE
What are your goals over the 12 week program? *
Why should REACT select you for this opportunity? *
What are you favorite hobbies? *
Do you drive? *
Do you work or are you in school? *
If you answered yes, please describe your work or school:
Rate your level of stress at home *
no stress
extreme stress
What other adaptive / therapy programs have you participated in? *
What time do you go to bed at night? *
Time
:
What time do you wake up in the morning? *
Time
:
How did you hear about REACT? *
If other, please explain. For referral, please let us know who referred you:
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