Online Application

If you prefer to print out and send in your application, please click here.

In an effort to provide the most safe and effective program, it is necessary for all clients to complete this application in its entirety. All information provided will remain confidential. If the client is under the age of 18, a parent or guardian must sign the application.

Last, First, Middle
Home number and street, city or town, state, zip code and country.
Name, Methods of Contact, Relationship to You
Cause of injury, level of injury, complete or incomplete, Asia score
Please list where and how often you attend therapy
Please list dates, where you were hospitalized and the reasons of your hospitalizations
Manual, electric or power assisted/manual
Briefly describe which type you use and your gait
Name, address, city, state, zip code. Length of stay.
Name, address, city, state, zip code. Length of stay.
Please list ALL medications by name, dose, frequency and when you started taking medication.
Please answer yes or no. Indicate YES for those that apply to you at present or have applied to you in the past.
Please answer yes or no. Indicate YES for those that apply to you at present or have applied to you in the past.
We do not interpret bone density reports. Clients must update bone density assessments annually.


The remainder of your application will be completed on your first day at Beyond the Chair. Thanks!