Referral Form

1. Referrer Information

Self Referral

Yes No

Company/Organization

2. Client Information

Telephone Number (Primary)

Telephone Number (Alternate)

3. Alternative / Emergency Contact Information

4. Extended Health Benefits Information

Do you have extended health benefits?

Yes No

Policy / Plan / Group / Contract #

Member / Certificate / ID #

Plan Holder Relationship to Client (if applicable)

5. Auto Insurance Information

Is auto Insurance information applicable to this referral?

Yes No

6. Legal Representative Information

Is legal representative information applicable to this referral?

Yes No

7. Reason for Referral

Service

Occupational Therapy Services Occupational Therapy Upper Extremity Treatment Social Work Services Case Management Services Rehabilitation Coaching Services PGAP - Progressive Goal Attainment Program Other (specify below)

Assessment / Specialty Services

Assessment of Attendant Care Needs (Form 1) Home Safety and Accessibility Assesment Preliminary Life Care Plan/Future Cost of Care Needs Assessment Life Care Plan/Future Cost of Care Needs Assessment Past Care Valuation Multidisciplinary Catastrophic Impairment Assessments (specify below) Disability Claim / WSIB

Medical Records

Yes - Please send medical records to sabrina@pwrehab.ca No Not applicable

Referral Requirements / Additional Comments

How did you hear about us?

Consent to Communication

I consent to further communication with Palmer Wellness & Rehab

Phone

Fax

E-Mail

Address

Client Portal

1. Referrer Information

2. Client Information

3. Alternative / Emergency Contact Information

4. Extended Health Benefits Information

5. Auto Insurance Information

6. Legal Representative Information

7. Reason for Referral

8. Referral Source

Empowering Independence and Enhancing Lives