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Referrer/Billing Details

Contact Person

Contact Number

Position

Fax

Email

Company Name

ABN

Mailing Address

Worker Details

Worker’s name

Date of Birth

Home Address

Work Address

Email

Language Spoken

Contact Number (H)

Contact Number (W)

Interpreter Required

Yes

No

Injury Details

Diagnosis

Date of Injury

Claim Number

Current Work Status

Current hours/week

Current weekly payment

Pre-injury hours

Nominated Treating Doctor

Address

Contact Number (Ph)

Contact Number (Fax)

File Upload

Please attach copies of all relevant documentation, including current medical certificate.

Employer Details

Address

Supervisor Name

Supervisor Contact (Ph)

Supervisor Contact (Fax)

Supervisor Contact (Email)

Referral Details & Instructions (please provide a brief summary of requirements)

Reason for referral

Auditing

Consultancy Services

Cogmed – Cognitive Training

Dragon Dictation Training

Initial Needs assessment

FCE

Mediation and Conflict Resolution

Medical Case Conference

RTW Coaching

Workstation assessment

Vocational assessment

Other

Please detail any further request or relevant information

Preferred Consultant

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Amount Approved + GST

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Referral will not proceed without an approval amount.

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Terms & Conditions

· All prices do not include GST
· Our terms of payment are strictly 30 days from the date of invoice
· Cancellation of assessment < 24 hours notice will incur a fee of 80% of the standard assessment time

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The Rehabilitation Specialists

YOUR GOALS, YOUR WAY

The Rehabilitation Specialists

WE CARE, WE CAN

Home
Services
Make a Referral
About Us
Contact Us
- Specific service/ project request
- Contact us

18000-73422 (REHAB)

Copyright by The Rehabilitation Specialists. All rights reserved.

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Copyright by The Rehabilitation Specialists. All rights reserved.

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SERVICES
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