Multiple Sclerosis Society of Portland, OR, Inc.
2901 SE 122nd Ave.
Portland, OR 97236
Phone: 503-297-9544
Fax: 503-297-6264
Email: candycehayes@msoregon.org
 
Date Sent:
Date Received:
Dr's Note:
Verification:
MSSP Office USE ONLY
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LMT Preference:    Male   Female   Either    |  Locale: Home   Office   |  Stairs: Yes   No    
Area:___________________________
Deadline: March 31, 2009
 
                         MSSP 2009 "Project Helping Hands"
                                                CLIENT APPLICATION
 
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Client Name                                                                                                                 Age
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Address                                                       City                 State                                            Zip
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Telephone                                                                             E-mail
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Emergency Contact & Telephone

1. Date Diagnosed: ______________________________

2. Current Doctor:  ______________________Telephone:  __________________

3. Do You Use Assistive Devices (walker, wheelchair, scooter)  No      Yes    
Specify:  ___________________________________________________________

4. Do you need help to transfer from wheelchair to bed?      No      Yes    
Comments:i_________________________________________________________
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5. “LMT” stands for licensed massage therapist.  Whom do you prefer to be seen by? 
Male     Female    Either
Comments:   ________________________________________________________

6. Are you capable of going to the therapist’s office?       No          Yes        

7. When would you like to begin receiving LMT visits? _____________________ 

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Signature                                                              Date             
 
Our office will contact you when we have found a volunteer LMT who meets your needs. Be sure to keep our office updated with your current address and telephone number.