ACCT Program Intake Form

Ability KC does not and shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, patients, students, clients, volunteers, subcontractors and vendors. Ability KC is not associated or affiliated with or sponsored by Shirley Ryan AbilityLab (formerly the Rehabilitation Institute of Chicago).

ACCT Intake Form

Step 1 of 5

Other Contact Information if Needed to Schedule this Appointment

Physician Information

Payment Information

School Information if Applicable