Contact

Vancouver, BC
Tel: 604.254.0444
Fax: 604.254.0447
Email: info@jrrehab.ca

Victoria, BC
Tel: 250.704.4437
Fax: 250.704.4438
Email: info@jrrehab.ca

To Make a referral, fill out the form below

* required fields

Referral Information

1. Relation to client

Relation to client i.e. OT, PT, Dr., insurance adjustor, family member, friend, etc.

2. Your Name*
3. Telephone Number* - -
4. Email

Client Information

1. Name of Client
2. Age
3. Gender Male Female

4. Street Address:
5. City:
6. Postal Code
7. Telephone Number - -
8. Claim Number
(if applicable)
9. Occupation
10. Currently Working? Yes No
11. Date of Injury
(mm/dd/yy)
12. Type of Injury
(Press CTRL to select more than one)
If other, please specify
13. Current Symptoms
14. Independent with Self-Care? Yes No
If No, Please comment

Emergency Contact Information - MUST be completed (See * below)

1. Emergency Contact Name
2. Telephone Number - -
3. Relationship to Client

Rehabilitation Information

1. Rehab Goals
(Press CTRL to select more than one)
Rehab Goals Additional Notes

2. Client Availability
(preferred days/time)

	M	T	W	R	F
Yes:
No:
Morn. (8:30-12:00)
Early Aft. (12:00-2:00)
Late Aft. (2:00-5:00)

3. Program Structure

Sessions per week:
Hours per session:
Start Date (e.g. mm/dd):
Proposed # of
for rehab:

4. Recommended Facility
5. Additional Information
(other therapies, meds, restrictions, etc.)

Fee Payer Information

1. Company Name:
2. Contact Name* 3. Contact Phone* - -
4. Contact Fax - -
5. Billing Address*

5a. Is there a lawyer associated with this file?

6. RA gender requested

Male	Female
No Preference
No RA at this time

7. Name of specific RA or Kinesiologist requested
8. Please email me a blank JR Rehab Assistant Treatment Plan

Yes
No, will email by (date)

If the Emergency Contact info is not presently available, please provide this information to the RA/Kinesiologist at the first meeting.