Insurance Referral Form Referral Source: Name of person completing this form*: Relationship to Client*: Self Family Physician Specialist Physician Case Manager Occupational Therapist Lawyer / Paralegal Other Healthcare Professional Name of Clinic/Company/Firm*: Address*: Phone*: Fax: Email*: Page Break 1Client Information: Client Last Name*: Client First Name*: Date of Birth*: Calendar Gender*: MaleFemaleNon-binaryOther Client Address*: City*: Postal Code*: Client Phone*: Client Alternative Phone: Client Email: Driver's License Number: License Status*: ValidMedically SuspendedUnsureNot applicable Client Mobility*: Able to walk without any mobility devicesAble to walk using a cane/poleUses a manual wheelchairUses a power wheelchairUses a scooter Is the client able to transfer into/out of a car seat?*: YesNoUnsure Page Break 2Medical Details: Reason(s) for Referral (check all that apply): Medical Fitness to DriveDriving with Adaptive ControlsDriving AnxietyPassenger AnxietyVehicle PrescriptionVehicle Access (for Passenger)Other If "Other", please specify: Please list relevant diagnosis, injuries, or symptoms: Please list relevant ICD-10-CA codes: Page Break 3Booking arrangements (Check all that apply): To book appointment please contact*: Contact client directly Contact family member/friend to book Preferred Assessment Location*: Saint CatharinesHamiltonOakvilleToronto – North YorkToronto – BramptonWhitbyKingstonClient's homeUnsure, please contact client Physician Information: Does the client have a physician?*: YesNo Page Break 4Insurance Company Information: Claim Number*: Policy Number: Date of Accident*: Calendar Insurance Company Name*: City or Town or Branch (if applicable): Adjuster Last Name*: Adjuster First Name*: Adjuster Telephone*: Adjuster Fax: Name of Policy Holder*: Applicant Other Is there other insurance coverage that may cover our services?*: YesNoUnsure Page Break 5Lawyer Information: Is the client being represented by a legal firm?*: YesNo Please let us know if you have any questions or comments related to this referral: How did you hear about us?*: I have referred before Saint Elizabeth Website Other Internet / web-search Presentation Conference Other Prefer not to say