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Skip Navigation
Multiple Sclerosis
Services
Outpatient Medical
Rehabilitation
Adult
Brain Injury
Concussion Care
Limb Loss
Pediatric & Adolescent
Seasonal Programming
Senior
Specialized Expertise
Spina Bifida
Spinal Cord Injury
Stroke
Vision
Therapeutic
Preschool
ABA
Outpatient Therapy
Therapeutic Preschool
Employment
Services
Ability KC Industries
Employment Services
Summer Work Experience
Speciality
Services
Assistive Technology
Aquatic Therapy
Driving Program
EXCEL Program
Neuropsychology
Rehabilitation
Technology
Admissions
Getting Started
Bill Pay
Insurance
Resources
Resource Library
FAQ
News
Blog
Events
Ability Luncheon
A Professional Conference hosted by Ability KC
Annual Groundhog Run
Community Events
All Events
About
History
Mission & Vision
Leadership
Annual Report
Partnerships
Locations
Areas Served
Stories
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ACCT Intake Form
Step
1
of
5
20%
Reason for ACCT referral:
*
Required
Adapted Computer/Digital Access
AAC Communication
Home Modifications
Adaptive Technology for Learning Disabilities
Office Ergonomics
Adaptive Gaming
Other/unsure
Current method of communication if being seen for AAC Communication:
Looks at what is wanted
Some speech but difficult to understand
Gestures
Some sign language
Currently using a communication device
Has tried a communication device in other settings
Other
If you selected "Other" for Current Method of Communication, please explain:
Behaviors to be aware of?
Yes
No
If so, please explain (hit, kick, bite, scratch, throw things, elope):
How do they handle being in the community or going to doctor's offices?
Ways to make them more comfortable for the appointment:
Any interests or preferred activities that they enjoy that will be motivating for them during this visit? (Please bring preferred object, toy, device, etc.)
Name of Individual Being Referred
*
Required
First
Last
Date of Birth
*
Required
MM slash DD slash YYYY
Age
*
Required
Address
*
Required
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County of Residence
*
Required
Cell Phone
*
Required
Home Phone
Email
*
Required
Sex
*
Required
Male
Female
Other
Race
*
Required
African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Marital Status
*
Required
Married
Widowed
Separated
Divorced
Single
Diagnosis
*
Required
Limitations due to diagnosis (please check all that apply for individual being referred):
Peripheral Vision Deficits
Double Vision
Difficulty Reading
Hearing Impairment
Left Arm Weakness/Paralysis
Right Arm Weakness/Paralysis
Decreased hand coordination
Left Leg Weakness/Paralysis
Right Leg Weakness/Paralysis
Paraplegia
Quadriplegia
I can walk
I use a wheelchair
Dysarthria
Aphasia
Cleft palate/ craniofacial
Apraxia
Developmental Delay
Chromosomal Abnormalities
Down Syndrome
Difficulty expressing wants/needs
Difficulty being understood
Orthopedic pain with sitting
Decreased safety in the home
Other/additional comments
Please list any other disabilities that may have any affect on this visit:
Onset Date
MM slash DD slash YYYY
Primary Method of Mobility
Motor Skills for Arm and Hand Function:
Can use hands to push buttons or targets on tablet or phone
Has arm movements but cannot control for targeted button selections
Other
Please list other:
Vision limitations to be aware of:
Other Contact Information if Needed to Schedule this Appointment
Name
*
Required
First
Last
Phone
*
Required
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Relationship
*
Required
Legal Guardian/Power of Attorney (if any)
First
Last
Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Relationship
Physician Information
Why are you being referred for this evaluation?
Please indicate who is referring you for this evaluation:
Physician
VR Counselor
Case Manager
Other
Please provide their name below:
*
Required
First
Last
If you chose "Other" to the question "Who is referring you for this evaluation?", please indicate the Agency referring you:
Phone
*
Required
Fax
Primary Care Physician Name (if different from Referring Physician)
First
Last
Phone
Fax
Payment Information
Who is paying for this evaluation?
*
Required
Yourself
Worker's Compensation
Vocational Rehabilitation
School
County Grant for Home Modification visits only
Commercial Insurance
Medicare
Medicaid Waiver for Home Modification visits only
Missouri Medicaid
Kansas Medicaid
Other
If you selected "Other", please explain:
If this is being paid through any form of medical insurance noted above, please provide the following:
Primary Insurance
Policy #:
Subscribers Name and Date of Birth:
Secondary Insurance
Policy #:
If you selected workers compensations please provide the case manager's name.
First
Last
School Information if Applicable
School Attending and/or provider of therapies being received:
Therapies being received, please specify (PT/OT/ST/ABA)
Once consent is in place, please enter School and/or Therapist contact information:
First Name
Last Name
Phone
Email
Are you receiving Home Health or Hospice?
Please make sure you have filled out this form thoroughly so that we may best provide the services you need. In the space below, please add any other information below that will be helpful to know for this intake or scheduling. Once complete, call (816)-751-7748 to confirm receipt of this intake.
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Multiple Sclerosis
Back
Services
Outpatient Medical
Rehabilitation
Adult
Brain Injury
Concussion Care
Limb Loss
Pediatric & Adolescent
Seasonal Programming
Back
Senior
Specialized Expertise
Spina Bifida
Spinal Cord Injury
Stroke
Vision
Back
Therapeutic
Preschool
ABA
Outpatient Therapy
Therapeutic Preschool
Back
Employment
Services
Ability KC Industries
Employment Services
Summer Work Experience
Back
Speciality
Services
Assistive Technology
Aquatic Therapy
Driving Program
EXCEL Program
Neuropsychology
Back
Rehabilitation
Technology
Back
Admissions
Getting Started
Bill Pay
Insurance
Back
Resources
Resource Library
FAQ
News
Blog
Back
Events
Ability Luncheon
A Professional Conference hosted by Ability KC
Annual Groundhog Run
Community Events
All Events
Back
About
History
Mission & Vision
Leadership
Annual Report
Partnerships
Locations
Areas Served
Back
Stories
Contact
Email Us
Volunteer
Internship
Careers
Referrals
Back