Extended Referral Form

Referral for Occupational Rehabilitation Services

Referrer *

Treating DoctorInsurerEmployerOther

Service Requirement *

Same EmployerNew EmployerOne-off AssessmentWorkplace Facilitated Discussion

Worker Details

Full Name *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Phone *

Fax

Email *

Date of Injury *

Claim Number *

Details of Injury *

Current Work Capacity

Has a current work capacityNo current work capacity

RTW Goal

RTW Same EmployerRTW New Employer

Pre-Injury Hours

Pre-Injury Role

Current Certificate of Capacity Details

Interpreter Required

YesNo

Language

Agent/Insurer Details

Agent/Insurer Full Name *

Company Name *

Address

Street addressStreet address line 2

City

State

Postcode

Phone *

Fax

Email - Agent/Insurer *

Team Number

Employer Details

Are the employer details the same as the Referrer details?

YesNo

Contact Full Name *

Contact Position

Company Name *

Address

Street addressStreet address line 2

City

State

Postcode

Phone *

Fax

Email *

Notes

Nominated Treating Doctor (NTD) Details

NTD Full Name *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Phone *

Fax

Email *

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