Referral Form*

The form below (print/PDF version here) can be submitted via fax (204-221-8847), website, or mailed in confidence to Apex Therapy Services. Should you have any further questions regarding services, costs, etc. of Apex Therapy Services, please contact the owner and Occupational Therapist, Mr. Russel Dyck O.T.Reg.(MB) at 204-415-3973.

*All supplied information is encrypted prior to transmission.

Client information

Name

Address

Email

Phone Number

Contact Person (if applicable)

Physician

Other health care personnel involved

Medical status/diagnoses (please include any applicable restrictions)

Funding source (if available)

Referral source (name and business/clinic)

Service(s) requested Service(s) requested Ergonomic/Workstation Assessment Physical Assessment (ROM, strength testing, mobility, fine motor skills, etc) Physical Demands Analysis Seating Assessment (e.g. wheelchair) Percentage of Duties Assessment Adaptive Equipment Assessment (home or workplace) Return-to-Work/Vocational Plan/Program Discharge Planning Personal Care Assessment School Assessment Housing/Accessibility Assessment Dependent/Care-Giver Assessment Cognitive Assessment (BrainFx or other) Cognitive Therapy Exposure Therapy Neuro Assessment/Therapy (e.g. ABI, Spinal Cord, etc) Mental Health Functional Assessment ADL (Activities of Daily Living)/Life-skills Therapy General Rehabilitation programming (can include physical, cognitive, and/or life-skills) Functional Capacity Evaluation (FCE) Permanent Impairment/Scar Assessment Other (specify below)

Other Services? Please specify.

Additional comments (e.g. timeline for assessment/report, etc)

Get In Touch

Contact

Referral Form*

Client information