Schedule an Evaluation

The first step in driver rehabilitation.

Fill out the form below to get started with Freedom & Mobility!

Client Information
Client Name*
First Last
Email*
Home Phone
Cell Phone
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth (mm/dd/yyyy)
Age
Referral Source
Agency
Email
Contact Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Send Invoice To:
How did you hear about us?
History
Is the client in a wheelchair?
- Yes
- No
If yes, indicate wheelchair type
Does the client have a vehicle?
- Yes
- No
If yes, indicate vehicle year, make, and model
Does the client have a valide driver's license or permit?
- Yes
- No
Client's Doctor Name
Doctor's Phone
Doctor's Fax
Additional Comments

Requirements For Getting Started

Applicants must consider the following requirements before scheduling an appointment:

Possess a current Driver’s License or learner’s permit.
Have some form of physical or intellectual impairment.
Provide medical clearance as needed

Coverage For Evaluation And Training Costs

Private/Self Pay
Worker´s Compensation
Vocational Rehabilitation
Veterans Administration
Private Insurance