Download and print out this form. When you have completed the form, send it via email to firstname.lastname@example.org or fax it to our office at (734) 936-3947.
Please contact us at (734) 763-3000 to confirm that we have received your documentation.
This form is to be filled out for Mental Health Conditions, ADHD, Autism Spectrum Disorders, and Acquired/Traumatic Brain Injuries.
This form is to be filled out for Chronic Health Conditions.