I understand that I am being referred by Vocational Rehabilitation for an assessment to determine my current physical and/or cognitive abilities as they relate to work.

I understand that:
- The assessment is not for the purpose of diagnosing a medical condition.
- I may be asked to perform physical or cognitive tasks that reflect typical job duties.
- I am expected to put forth my best effort but can stop the assessment at any time.
- The results will be shared with my VR counselor to assist in vocational planning.

I have had the opportunity to ask questions and all of my questions have been answered.

I acknowledge that I have been provided with a notice of privacy practices and understand how my personal health information may be used and disclosed for the purpose of conducting this evaluation and communicating with my referring counselor.

I authorize Tilton’s Therapy, Inc/Tilton’s Therapy for Tots and its representative to obtain or release medical or other relevant records to/from my healthcare providers or other relevant professionals as necessary to complete the Functional Capacity Assessment and/or any other related assessments/treatments to coordinate with my Vocational Rehabilitation counselor. 

This authorization is valid for one year from the date of my signature below and may be revoked at any time in writing.