Special Needs Solutions

treatment Bench

Use the Treatment Bench graphic to fill in the necessary measurements and information below. Then simply "Submit" it to us. If you have any questions, feel free to call or email us. We will be in touch.

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Person recommending equipment

First Name

Last Name

Your Name

First Name

Last Name

Email Address

Phone

(###)

###

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Client's Name

First Name

Last Name

Client's Birthdate

Bench HEIGHT

Bench WIDTH

side to side

Bench DEPTH

front to back

Adjustable or Fixed?

1" Foam Padding?

If padded, Vinyl Color?

First and Second choice of color

Special Instructions

Anything else you want us to know

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treatment Bench

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special Needs Solutions is a tax-exempt 501(C)(3) nonprofit organization. Your gift is tax-deductible as allowed by law.