• 605-430-9361

MOON’S BRIDGE OT EVALUATION REQUEST FORM

Moon’s Bridge, Inc. will conducted an Occupational Therapy (OT) Evaluation based on a medical
professional request and/or a parent request. This will be conduct at the home site and/or at a
community based setting that the parent(s) are in agreement with Moon’s Bridge.

All fields marked with an asterisk (*) are required

ATTACH AT LEAST ONE OF THE FOLLOWING:


A. Request from the primary care / other physician for an OT Evaluation
B. Current OT Evaluation and/or Progress Notes from the treating OT
C. Current Clinical Notes from a therapy provider(s) supporting the need for an OT Evaluation

STATEMENT OF ACCURACY FOR APPLICANT


I hereby affirm that all the above stated information provide by me is true and correct to the best
of my knowledge. I also consent that if chosen as a recipient of equipment my picture may be
taken and used to promote Moon’s Bridge (MB) , Inc. OT Evaluation program.
I hereby understand I will not submit this application without all required attachments and
supporting documentation. Incomplete applications or applications that do not meet the criteria
with not be considered for this program.

CHECKLIST___APPLICATION ___ (1 FORM) from QUESTION # 6 __ CURRENT OT CONTACT
INFO IF APPLICABLE

MAIL COMPLETE APPLICATION PACKAGE TO MOON’S BRIDGE, INC
C/O MONIKA SHUMBO-POISSANT, OTD, OTR/L, ATRIC
3958 SOUTH DEVANE DRIVE – YUMA, AZ – 85365
Cell Phone – 605-430-9361 Email – Moon@moonsbridge.com

There is no deadline for this application to be received by Moon’s Bridge, Inc. office.
Evaluations are ongoing based on the need of the community, as well as the availability of an

OTR to conduct the evaluation.