Option 1: Download and fax

If you’d like to fax your referral, click the below button to download our referral form and fax the completed form to: 1-866-293-6930.


Option 2: Submit online

If you’d like to submit your referral online, complete the below form and click “submit.”

Email*:

* indicates a required field

Client/Claimant Information:

Client First Name*:

Client Middle Name:

Client Last Name*:

Client Gender*:

Client Street Address*:

Client Suite Number:

Client City*:

Client Province*:

Client Postal Code*:

Client Phone Number*:

Client Date of Birth (yyyy/mm/dd)*:

Claim Number*:

Policy Number*:

Date of Loss (yyyy/mm/dd)*:

Other:

Can we contact the client directly?*: yesno

Designated CAT?*: yesno

Transportation Required?*: yesno

Interpreter Required?*: yesno

Language Type?:

Special Needs/Accommodations Required?*: yesno

Describe:

Insurance Information (if applicable):

Insurance Company:

Adjuster Name:

Insurer Phone Number:

Insurer Ext.:

Insurer Street Address:

Insurer Suite:

Insurer City:

Insurer Province:

Insurer Postal Code:

Insurer Fax:

Is the name of the Policy Holder the same as the Applicant? yesno

If no, what is the Policy Holder's name?:

Legal Representation (if applicable):

Law Firm:

Lawyer Name:

Law Clerk Name:

Law Firm Phone Number:

Law Firm Ext:

Law Firm Fax:

Law Firm Email:

Law Firm Street Address:

Law Firm Suite:

Law Firm City:

Law Firm Province:

Law Firm Postal Code:

Referring Party Information (if different from the Insurer/Lawyer):

Referring Company:

Referrer Name:

Referrer Phone Number:

Referrer Ext:

Referrer Fax:

Referrer Email:

Referrer Street Address:

Referrer Suite:

Referrer City:

Referrer Province:

Referrer Postal Code:

Would you like us to contact you for further detail or customization of a program? yesno

Notes:

Vocational Services (select all that apply):

Cognitive Demands Analysis (CDA)
Physical Demands Analysis (PDA)
Transferable Skills Analysis (TSA)
Job Site Analysis (JSA)
Graduated Return-To-Work Plan (GRTWP)
Job Coaching
Workplace Situational Assessment
Psychoeducational Assessment
Vocational Assessment – includes TSA
Psychovocational Assessment (2 Day) - not for SABS Claims
Psychological Component and Review of Vocational Assessment (formerly psychological component of Psycho-Vocational Assessment for SABS Claims)
Cognitive Vocational Assessment - not for SABS Claims
Own JobAny OccupationOwn Job & Any Occupation
Cognitive Psychovocational Assessment - not for SABS Claims
Own JobAny OccupationOwn Job & Any Occupation
Job Development/Placement Service (hours dependent on Client needs)

Number of Hours:

Career Counselling/Vocational Rehabilitation Counselling (hours dependent on Client needs)

Number of Hours:

Essential Self-Marketing Tools Workshop (Resume Building and Writing Winning Letters)
Fundamental Job Search Techniques Workshop (Hidden Job Market and Interview Preparation including Mock Interview)
Job Goal Setting Workshop (Identifying Transferable Skills, SMART Goals, Researching the Labour Market)
Labour Market Research (LMR) – Web Based (includes 3 jobs)

Please list job options (if not being done in combination with a Vocational Assessment):

Labour Market Research (LMR) – Employer Contact (includes 3 jobs)

Please list job options (if not being done in combination with a Vocational Assessment):

Education Research

Please list training program(s) to research:

Medical/Paramedical Services: (select all that apply):

Addendum
File Review
Executive Summary
Cardiology Assessment
Internal Medicine Assessment
Chiropractic Assessment
Kinesiology Assessment
Psychiatry Assessment
Dental Assessment (Dentist)
Neurology Assessment
Psychology Assessment
Ergonomic Assessment
Neuropsychology Assessment
Registered Nursing Assessment
Ophthalmology Assessment
Social Work Assessment
Orthopedic Assessment
Physiotherapy Assessment
Occupational Therapy Assessment
Massage Therapy Assessment
General Practice Assessment
Otolaryngology (ENT)
In Home Assessment
Physiatry Assessment
Speech-Language Pathology Assessment
Functional Abilities Evaluation (FAE)
Cognitive Functional Abilities Evaluation
Oral & Maxillofacial Assessment (Dental Surgeon)
OTHER :

Type of service (if applicable)

Section 16
Section 44
Section 46

Benefit (If applicable):

Pre 104
Post 104
Attendant Care
Income Replacement Benefit
Non Earner Benefit
Caregiver Benefit
MIG Determination
Disability
Housekeeping and Home Maintenance Benefit
Medical / Rehabilitation - OCF 18

date, signee, amount: