Children's Assistive Technology Service
Comm. Loan Library
CheapTalk 4 Direct
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CheapTalk 4 Direct

$0,00
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SKU:
10101105721665
Items available:
0
Communication Loan Library: ¥ Items available only ON LOAN for 3 months ¥ Must be recommended by the childÕs Speech Therapist Ð please put speech therapist contact information in the ÒnotesÓ section of the item request form ¥ These items are available only to Hampton Roads residents
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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

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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?
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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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