Contact | Mindful Movement The

Referring Person's First Name

Referring Person's Last Name

Referring Person's Email

Referring Person's Phone Number

Supported Person's Name

Supported Person's Date of Birth

Supported Person's Phone Number

Supported Person's Address

Supported Person's Best Point of Contact

Supported Person's Service Coordinator

Please include name, phone number, and email

Is there a legal guardian or authorized decision-maker?

Yes

No

If yes, Guardian/Decision Maker Name

If no, type No.

PT Referral Justification (check all that apply)

Other Referral Justification

Additional Notes

I have read and agree to the Informed Consent and Available Services below this form. I acknowledge that I have chosen Mindful Movement Therapy and Wellness LLC as my provider of Physical Therapy consultation services under the DD Waiver. I understand that I have the right to select from qualified providers, and that Mindful Movement Therapy and Wellness LLC offers PT consultation as outlined in the Individual Support Plan (ISP).

Signature for Informed Consent and Available Services

I have read and agree to the Telemedicine Consent below this form.

Signature for Telemedicine Consent

The team at Mindful Movement Therapy and Wellness LLC (including administrators and any providers designated on the ISP) is authorized to exchange relevant health information as needed to provide Physical Therapy Consultation services on behalf of the Supported Person identified in this form.

Signature for Release of Information

The above consents are valid unless revoked in writing by the Supported Person or their authorized representative.

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