Legs of a child wearing white orthopedic braces and socks seated in a wheelchair with a red dress.

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Our Sponsors

C.A.T.S. provides for the re-use of pediatric rehabilitation equipment and assistive technology devices in Virginia. We serve as a no-cost resource for children with disabilities who need adaptive equipment and whose families have limited resources.

EIN

a 501(c)3 public charity
EIN: 46-4866068

Your Request

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The below information is required for our record keeping and equipment fitting purposes.

Parent/Guardian Info

Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Email

Therapist Info

Therapist Name
Therapist Phone
Therapist Email

Child Info

Child Name
Race
Age
Height
Weight

Other Info

Why did you choose to obtain an AT device/service from our program?
What type of insurance does the child have?
Has the requested equipment been denied by Insurance?
Persons in Household
Family Income Range
Is this child currently a client of the Department of Aging and Rehabilitative Services (DARS)?
Diagnosis
The primary reason for which the child and family needs an AT device or service is related to:
Will equipment be used at home, school or both?
Which of the following reflects your level of satisfaction with this means of obtaining needed equipment?
Order Notes (optional)

Please Note:

The fields above are required to complete your equipment request. We also require a signed Equipment Release Form to process your request. Please sign the Equipment Release Form at the button below.

Required Equipment Release Form
Liberación de Equipo

Equipment Release

Please Read and Sign before submitting your request.

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