Form Mc 2113 P - Medical Therapy Unit (Mtu) Summary
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1Department of Health Care Services
State of California—Health and Human Services Agency
California Children’s Services
MEDICAL THERAPY UNIT (MTU) SUMMARY
Name
(last)
(AKA)
(first)
Date of birth
State file number
Educational placement
Diagnosis
Therapist(s)
MTU/company
Evaluations:
❒ ADL
❒ ROM
❒ MMT
❒ Home evaluation
❒ A/V
❒ Motor maturity
❒ Reflex testing
❒ Sensory
❒ Perception
❒ Other: ___________________________________
Referral date
Date of report
Period covered
Number of treatment units scheduled
Given
MC 2113 P (09/07)
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