CANADIAN REHAB CONSULTANTS REFERRAL FORM
Please complete this Referral Form and click on the Submit button
REFERRAL SOURCE NAME:
COMPANY:
ADDRESS:
POSTAL CODE:
ASSIGNMENT DATE:
TEL:
EXT:
FAX:
CLIENT NAME:
CLAIM # / POLICY #
ADDRESS:
POSTAL CODE:
INJURIES:
DATE OF LOSS:
DATE OF BIRTH:
TEL. (H):
TEL. (B):
PHYSICIAN NAME:
ADDRESS:
POSTAL CODE:
TEL.:
FAX:
EMPLOYER NAME:
ADDRESS:
POSTAL CODE:
CONTACT:
POSITION:
TEL.:
EXT.:
FAX:
ASSIGNMENT TYPE:
In-Home ADL Assessment
SECTION 38
SECTION 42
Address Caregiving in IHA
Address Housekeeping in IHA
Address Attendant Care in IHA
Vocational Assessment
Psychovocational Assessment
Job Site Assessment
Ergonomic Assessment
Case Management – MVA
pt.
Case Management - LTD
pt.
Attendant Care (Form 1)
Return to ADL Program
Return to Work Program
Home Exercise Program
Housekeeping Assessment
Caregiving Assessment
Transferable Skills Analysis (TSA)
Other:
SPECIAL CONSIDERATIONS:
Contact Referral Source
Contact Lawyer; if YES please provide details:
Report to be signed by Client before submitting
Report to be signed by Physician before submitting
Report to be signed by Employer before submitting
Meet with Physician to obtain medical release
Assistive devices authorized
Meet with Injured Client
Meet with Physician
Meet with Employer
Meet with Other:
Interpreter Required (Language):
Use Insurance Co. Forms
No Signatures Required
Other:
OTHER:
225 Duncan Mill Road, Suite 302, Toronto, Ontario, M3B 3K9 • 416-445-5000 or Toll Free 1-800-265-4883 • Fax 416-445-1090