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 and contact information

Medical status/diagnoses (**please include any applicable restrictions and attach applicable medical documents)

Funding source and method of payment ( **NOTE: pre-authorized payment may be required. )

Referral source (name. business/clinic, contact)

Service(s) requested: (Please check all that apply) Service(s) requested: (Please check all that apply) Ergonomic/Workstation Assessment Physical/Job Demands Analysis Percentage of Duties Assessment Return-To-Work Planning Housing/Accessibility Assessment Adaptive Equipment Seating/Positioning (wheelchair or otherwise) Functional Capacity Evaluation (FCE) Cognitive Abilities Evaluation (CAE) Mental Health Functional Assessment/Intervention Exposure Therapy ADL/Lifeskills Therapy Neuro Assessment/Therapy (e.g. ABI, Spinal Cord) Physical Assessment (ROM, strength, mobility and fine motor skills) Personal Care Assessment (PCA) Dependent Care Assessment (DCA) Permanent Impairment/Scar Assessment Hospital Discharge Planning Other (specify below)

Other Services? Please specify.

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