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: