Click to Donate Today!

logo web

Do You Need Assistance?

NAF Service Counties 2023 zoom

Are you living with a spinal cord injury or a spinal cord disability/birth defect? NAF's mission is to help with mobility equipment, home modifications, vehicle modifications and technology to ensure maximum independence and self-sufficiency for our clients.

Applications can be submitted at any time. Please complete the following application online and submit it to NAF. We will contact you after the application is received. Thank you for your interest in NAF.  Applications must be completed by a physician, therapist, or hospital case manager and clients must not have alternative means to receive assistance.

Client Application Form



Birthdate (MM/DD/YYYY):
Gender:
Ethnicity:




County:
Person Submitting Application:
Person Submitting Application Email:
Person Submitting Application Phone:
Primary Contact First Name:
Primary Contact Last Name:
Primary Contact Email:
Primary Contact Phone:
Patient has children at home:
Ages of children:
Describe spinal cord injury (level and cause ie: MVA, Fall, etc.) If not a traumatic injury, please explain:
Type of assistance requested:
Describe patient's needs in order of importance:
Patient Discharge Date (MM/DD/YYYY):
Will patient be using catheters:
Is patient insured:
Insurance Company:
Does patient have Medicare/Medicaid:
Describe other program eligibility:
Patient is a veteran:
Social Worker First Name:
Social Worker Last Name:
Social Worker Email:
Social Worker Phone:
© Neuro Assistance Foundation • a 501(c)(3) Public Charity
(214) 288-5438 • Contact • Sitemap • Website by: The RWM Company

    

Neuro Assistance Foundation
2320 Bridgewood Drive
Keller, TX 76262