REFERRAL FORM FUNCTIONAL DRIVING EVALUATION REFERRER INFORMATION Referrer Name and Title: Referrer Company Name: Referrer Tel #: Referrer Email: DRIVER INFORMATION First Name: Last Name: Date of Birth: Gender: Male Female Other PHN: Address: (100 chars left) Telephone #: Email Address: Date of Loss: Claim/File # Driver’s License #: License Expiry Date: Driver’s License Status: Please select one Valid Cancelled Unknown REFERRAL INFORMATION DIAGNOSIS: (250 chars left) REASON FOR REFERRAL: Functional Driving Evaluation (FDE): Driver’s ability to compensate for skill deficits (cognitive, visual, physical and behavioral) will be evaluated by occupational therapist during in-clinic and on-road testing. Please choose: Class 5/7 Class 1-4 Vehicle Modifications: FDE for driver’s requiring modifications (hand controls, left foot accelerator, spinner knob) Yes No Unsure PLEASE LIST MODIFICATIONS REQUIRED Can the driver independently transfer into a sedan sized vehicle? Yes No Unsure Does the driver require any transfer equipment? Yes No Unsure PLEASE LIST REQUIRED TRANSFER EQUIPMENT Does the driver use mobility aids such as a wheelchair or power mobility? Yes No Unsure PLEASE LIST MOBILITY AIDS USED: IF DRIVER USES A WHEELCHAIR PLEASE CLARIFY IF IT IS RIGID OR COLLAPSIBLE Has funding been confirmed? Yes No PHYSICIAN INFORMATION Family Physician: Physician Address: (100 chars left) Physician Tel #: Physician Fax #: FUNDER INFORMATION Funder Name and Title: Funder Company Name: Funder Tel#: Funder Email: Functional Driving Evaluations are conducted by registered Occupational Therapists. Evaluation protocols meet the standards set out by the Driver Medical Fitness Program RoadSafetyBC. Please contact our Service Coordinator at 604.681.9293 for more information about our Driver Rehabilitation Program. Submit Thank you for completing our driver rehab referral form – we will contact you soon. Please turn on javascript to submit your data. Thank you! OK
