COMMUNITY THERAPISTS REFERRAL FORM Please complete this short referral form and we will get back to you quickly to confirm your requirements and arrange services. If your matter is urgent, call 604-681-9293 or 1-800-591-9477 and press “1” to speak with a Service Coordinator. I am inquiring about: Click here to select Counselling OT – Return to Work OT – Return to Function OT – Hospital Discharge OT – Functional Driving Evaluation/Rehab OT - Paediatrics Ergonomic Assessment Kinesiology – Home/Gym/Pool Rehab Assistant Services PT – Home Visits Life Care Plan / Cost of Future Care Functional Capacity Evaluation I am the client’s: Funder (payer) Lawyer Occupational Therapist Physiotherapist Other healthcare provider Family member or Guardian I am the Client Initial Assessment is Funded By Client Address Client Diagnosis/ Primary Health Issue Service Requirements & Comments MY CONTACT INFORMATION First Name: Last Name: Organization/Company: Phone Number: Email: How did you hear about us? Colleague/Health Professional Internet Search Google Ad Facebook Ad Conference Other Submit Thank you for completing our referral form – we will contact you soon. Please turn on javascript to submit your data. Thank you! OK
