NWH Rehabilitation Forms
To save time at your upcoming rehabilitation appointment at Northern Westchester Hospital, you can complete this paperwork in advance and bring it to your appointment. These rehabilitation forms are intended for patients visiting our Physical, Occupational, and Hand Therapy programs, as well as appointments within the Speech Therapy department.
Prior to arriving at your first appointment, you can print the attached forms that are relevant to your visit, fill them out fully, and bring them with you at your scheduled time.
Otherwise, the same forms will be available to you when you arrive for your appointment. We look forward to seeing you soon!
Department of Rehabilitation Services Patient Questionnaire - Intended for patients receiving physical therapy. This questionnaire highlights painful areas, forms of pain, pain ratings, symptoms, and more. Patients are encouraged to be as thorough as possible.
Speech-Language-Swallowing Intake Form - Provided for speech therapy patients with issues related to speaking, language, and swallowing abilities. This form provides an opportunity to detail any relevant symptoms and medical complications, including medical history and goals for therapy. Patients are encouraged to be as thorough as possible.
Notice of Privacy Practices Acknowledgment of Receipt - This form confirms patient receipt of Northern Westchester Hospital's Notice of Privacy Practices. Please read through the notice, and sign and date where indicated. Note that this attachment also includes therapy consent forms.
Have questions about any of the above rehabilitation forms? Feel free to contact the Northern Westchester Hospital Rehab and Ambulatory Care center with comments, queries, or concerns by phone at (914.458.8700 or online. We want your visit with us to be as smooth as possible.