Referral Form

Billing Information
(If Claim being handled by independent Adjuster, please include Name of Primary Insurance Company)
Company*
Contact Name*
Email*
Phone*
Phone extension?
- Yes
Ext. Number
Fax
Client Information
Policy/Claim Number and Policy Holder are required
Claimant First Name*
Claimant Last Name*
Claim Number*
Policy Holder*
Policy Number*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
DOB
MM slash DD slash YYYY
DOL
MM slash DD slash YYYY
Interpreter Language
Email*
Nature of Injury
Extended Healthcare Provider
Name
Group #
Policy #
Cert #
Name of Plan Member (Employer)
Family Member/Guardian
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Physician
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Legal Rep
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Case Manager
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Comments
Submitted by
Please complete this section If you are submitting this form on behalf of the patient:
Name
Phone
Service Required
Injury Management and Return to Work
- ABI Assessment & Treatment
- Assessment of Attendant Care Needs (Form 1)
- Behavioural Therapy
- Cognitive Demands Analysis
- Concussion Management
- Driving Evaluation
- Employment Counselling
- Ergonomic Assessment
- Exercise Programming
- Hand & Upper Limb Assessment & Treatment
- In-Home Occupational Therapy Assessment & Treatment
- Job Coaching / RTW
- KinesiologyServices
- Labour Market Survey
- Medical Case Management
- Physical Demands Analysis/Job Site Analysis
- Physiotherapy Assessment and Treatment
- Rehabilitation Therapy
- Return to Work Programming
- Social Work Assessment & Treatment
- Transferable Skills Analysis
- Vestibular Rehabilitation
Assessments & Claims Resolution Tools
- Functional Abilities Evaluation - 1 day
- Functional Abilities Evaluation - 2 day
- Future Care Costs Analysis
- Gos-E Assessment
- MultiMed Assessments -CAT
- Situational Assessment
- Vocational Evaluation
- WSIB Claims Management
Specialty Programs
- AccessAbility –Home Accessibility Assessment
- CAP –Claims Assistance Program–STD claims
- PGAP –Progressive Goal Attainment Program
- QuickCare™ –Discharge Planning
Consent*
I consent to further communication with DMARehability.
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Make a Referral

Our interdisciplinary team consisting of Occupational Therapists, Physiotherapists, Physicians, Kinesiologists, Social Workers, Speech Language Pathologists, Vocational Placement Specialists, Rehabilitation Therapists, Psychologists, Behaviour Therapists, Case Managers, and Registered Nurses work with the whole person, taking into account physical, social and emotional effects of an injured party.

DMARehability offers fully integrated, multidisciplinary services, to meet the needs of individuals with complex care needs.

Service available throughout Ontario – for a complete listing of our office locations please click here or email us at [email protected]

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Our Team

Please contact our intake coordinators to request c.v's of our professional staff.

[email protected]

Referral Form

Billing Information

Client Information

Extended Healthcare Provider

Family Member/Guardian

Physician

Legal Rep

Case Manager

Submitted by

Service Required

Our Team