General Referral Form - Critical Trauma Therapy

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Client's Full Name(Required)

Date of birth (YYYY/MM/DD)(Required)

YYYY slash MM slash DD

Email(Required)

Phone(Required)

Client's Address(Required)

Street Address Line 2 City Province Postal Code Country

WHAT CAN WE HELP YOU WITH ? (PLEASE CHECK ALL THAT APPLY)

Psychological Assessment

Addiction & Substance Use Rehabilitation Services

Psychotherapy Counselling

Occupational Therapy Assessment and Treatment Services

Cognitive Behavioural Therapy (CBT) Dialectical Behavioural Therapy (DBT)

Functional Cognitive Assessment & Cognitive Remediation Program

Mental Health Driving Assessment & Driving Anxiety Treatment

Hospital Discharge Planning/Community Integration

Family/Marital Counselling

Acquired Brain Injury/Post-Concussion Program

Cognitive Behavioural Therapy for Insomnia

Return to Work Planning/Vocational Interventions/WSIB

Restorative Yoga

Home/Community Safety Interventions

Pediatric/Adolescent/Youth Counselling

Pediatric Occupational Therapy Interventions

Social Worker Services and Counselling

Assistive Devices Prescription/Walker/Wheelchair Seating (ADP)

Vocational Counselling

Geriatric/Fall Prevention Program/Healthy Aging Program

Grief/Bereavement Counselling

Dietitian Services

Chronic Pain Program

Case Management Services

Home Accessibility and Modifications Assessment

Orthopaedic Injury Management (Fractures, Spinal Cord Injury, Amputation, etc.)

Motor Vehicle Accident

List of injuries AND/OR DIAGNOSIS

Do you want Direct or Virtual Services?

I prefer in-person services.

I prefer virtual services.

Funding Source

Motor Vehicle Accident

Date of Accident(Required)

MM slash DD slash YYYY

What Company do you have coverage with?

What is the Policy Number?

What is the ID Number or Group Number?

Do you know your coverage limit?

Are you the Policy Holder?

Yes

If not, name of person who is?

Do you have a Guardian, Power of Attorney, or Substitute Decision Maker?

Yes

If yes, please provide:

Name of Power of Attorney

Phone Number of Power of Attorney

Health Benefits

Extended Health Benefits Information

Do you have Extended Health Benefits? * Benefits through employer such as Manulife, Green Shield, Great West Life, etc.

Yes, I have benefits!

No, I do not have benefits.

If yes, what company are your extended health benefits with?

Policy Number

Auto Insurance (if applicable)

Claim Number

Date of INJURY OR ACCIDENT (yyyy/mm/DD)

MM slash DD slash YYYY

insurance adjuster

insurance company

PHONE NUMBER

Fax Number

Email address

Legal Information (if applicable)

Lawyers Name

Law Firm

Phone Number

Email Address

Employment Information

Are you currently working?

Yes

N/A. Minor

Untitled

First Choice

Second Choice

Third Choice

Are yoy currently working?

yes

N/A . Minor

Were you working at the time of your accident or injury?(Required)

Yes

N/A . Minor

Impairments Experienced - please check all that apply

Do you have any pre-existing injuries or illnesses?(Required)

Physical Symptoms

Headaches

Nausea/vomiting

Fatigue/low energy

Changes in taste

Sleep disturbances

Changes in hearing

Nightmares

Weight loss

Difficulty initiating sleep

Weight gain

Difficulty maintaining sleep

None of the above

Visual impairments

Other

If other please specify

Psycho-Emotional Symptoms

Irritability and/or anger

Social isolation/withdrawal

Anxiety

Stress

Driver, passenger/pedestrian anxiety

Panic attacks

Depressed mood

Lack of initiation/motivation

Emotional lability/bouts of crying

None of the above

Thoughts of self-harm or to others

Other

If other please specify

COGNITIVE SYMPTOMS

Concussion

Speech/language changes

Poor attention span

Difficulties with planning and organization

Memory issues

Problem solving difficulties

Delayed processing speed

Impulsivity

Executive functioning delays

None of the above

Cognitive fatigue

Other

Of other please specify

Has your life been affected in any of these areas?(Required)

Managing self-care

Community access

Difficulties engaging in daily activities

Banking

Work

Grocery shopping

School/education

None of the above

Caregiving

Other

Housekeeping/home maintenance chores

If other please specify

Referred by contact information

Referred By

Referral Email

Referral Phone Number

REFERRAL MAILING ADDRESS

Street Address Line 2 City Province Postal Code Country

Name

This field is for validation purposes and should be left unchanged.