Email - Referral Form

Client Information
Name
[First/Last]

Email
Address
City
Postal Code
Tel. #:
Home
Cell
Alternate
DOB
[mm-dd-yyyy]

DOL
[mm-dd-yyyy]

Description of Injuries

Legal Rep Information
Name
[First/Last]

Company
Address
City
Postal Code
Tel. #:
Business
Alternate
Fax
Additional Information
Family Dr
Employer
Treating Team

Insurer Information
Auto LTD WCB Other:
Name
[First/Last]

Company
Address
City
Postal Code
Claim #
Tel. #:
Business
Fax
Cell
Invoice to Insurer
Legal Representative
Employer
Other:
Rate Non-cat - auto
Cat - auto
Non-cat - reg
Cat - reg   
Benefits Applied for
[if applicable]
Att Care
HK
CG
IRB
Non-earner
Copy Reports to Insurer
Legal rep
Family Dr
CM
Client
Other:

Requested Services
At Hospital
Discharge Planning
Attendant Care
Case Mgt

In Community
Reintegration
Exercise/ Conditioning

Also

Rehab Coordination
Case Mgt
Future Care Cost Analysis/ LCP
File Review
Other:

At Home
Attendant Care
Housekeeping
Caregiving
Non-earner
Assistive Devices
Intervention
Return to ADL
Home modification
Home Safety
Cognitive Assessment/ Intervention
Physiotherapy
Other:

At Work
Early RTW Program
RTW Planning
Return to School
Ergonomic Ax
JSA with PDA
JSA with CDA
FAE – Physical
FAE – Cognitive
PGAP
Transferable Skills
Labour Market Survey
Job Search Job Coaching


Additional Notes

Disclaimer:

Important Note: By pressing submit, this form and the information on this form will be transferred by email to Complex Injury Rehab Inc. Once received, Complex Injury Rehab Inc. is committed to ensuring confidentiality and privacy, as outlined in our privacy policy. However, Complex Injury Rehab Inc. is not responsible or liable for any possible breach of confidentiality during the transmission process.

Alternatively, you can fill out our printable form and fax to our attention at: 905-839-9444.

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