GREAT STRIDES - A company committed to improving the lives of special needs children and their families.

Request for Assessment

After we review your Request for Assessment form, we will contact you by phone to discuss further if your child is appropriate for a Trial in the Mike Hart Walker. If it is determined that your child is appropriate, a Measurement Form (Provided by us) will need to be filled out by your child’s Physical Therapist and we will schedule your child for a trial appointment.

We strongly urge that your child’s Physical Therapist be present or that you plan to video this appointment as all Insurance Companies require a written Letter of Justification by your child’s Physical Therapist in order for them to cover this device. See our FAQ page (Frequently Asked Question’s) for further information regarding the MkIl Hart Walker being covered by Insurance.

The first trial appointment is free of charge and takes about 1 ½ hours of time.

If you do not reside in the Northeast section of the United States, please visit our FAQ page for contact information of other providers in the United States. Feel free to fill out the Request for Assessment, we can forward that information onto the provider in your area.

Please complete the following:

Note: We will not disclose your email address or any other information you enter on the greatstridesforcp.com website to any third party.

Please enter appropriate information for the individual requiring assessment below:

*First Name:

*Last Name:

*Diagnosis:

*Gender:

Male

Female

*Age:

*Weight:

*Height:

*Parent/Guardian:

*Address Line 1:

Address Line 2:

*City:

*State / Province:

*Zip / Postal Code:

*Home Phone:

Work Phone:

*Enter a valid email address:

Therapist Name:

Therapist Phone:

Best Time to Contact You:

How did you hear about Great Strides?:

Google
Printed Ad
Brochure
Doctor or Medical Personnel
Friend or Relative
Other (please describe below)

Additional Information:
(Please provide us with additional information, ie; surgical interventions, current orthotic devices/equipment etc.)