Integrated Occupational Health Services

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Occupational Therapy Referral Form

Please complete all sections. We will contact you by phone within one business day to schedule your appointment or to review your case.

Thank you for your interest in IOHS. We look forward to caring for your occupational therapy needs!

Client Name:

Address:

Telephone #:

Referring Agent:

Agency:

Telephone #:

Billing Agent:

Date of Injury:

Claim #:

Treating Physician:

Diagnosis:

Date Last Worked:

Is the client medically cleared to return to work?
Yes No

Are there any medical restrictions? (Specify):

Pre-injury Employer:

Contact Person:

Occupation:

Employer Telephone:

Is the client’s pre-injury employment available?
Yes No

If not, is alternate employment available?
Yes No

What questions do you want answered from this referral?

SERVICE:(Please select only one.)

For a brief explanation of each, hold your mouse over that service.

   For more detailed information, click on the name to open that page in a new
   window. To complete this form, simply close that new window once you have
   finished reading it.

1. Functional Capacity Evaluation

2. Targeted Functional Assessment

4. Functional Back Evaluations

5. Pre-employment Screening

6. Case Management

7. Job Site Analysis

8. Ergonomic Workstation Review

9. Ergonomic Risk Analysis/Adjudication Assessment

10. Home Demands Analysis

11. Clinic Based Occupational Rehabilitation

12. Worksite Occupational Rehabilitation

13. Enhanced Fitness Program

14. Education/Ergonomic Consultation

15. Back Injury Prevention Program

16. Functional Hand Assessment and Customized Splints

17. Foot Assessment and Customized Orthotics

18. Progressive Goal Attainment Program (PGAP)

19. Mental Health Return to Work Services

20. Medical-Legal Consultation

21. Future Cost of Care Assessment

22. Other (describe service requested)

Please add any additional information you feel is of benefit:

Thank you. By completing this form, you have allowed us to process your request as quickly as possible.

Please click the "Submit" button below, and remember when you come to your initial appoint, to please bring with you all recent medical documentation.

27 AUSTIN STREET • ST. JOHN'S • NL • CANADA • A1B 4C3
709•722•9675 • Fax 709•722•9677 • info@iohs.nf.net