Client Name: ___________________________
PHIN: _________________________________
Address: ______________________________
City/Postal Code: _______________________
Phone #:_______________________________
Date of Birth (dd/mm/yyyy): ______________
MFRN (MHSC): _________________________
Gender: _______________________________
(or use client label)
COMMUNITY THERAPY SERVICES INC.
Referral for Occupational Therapy / Physiotherapy
201-1555 St. James Street
Winnipeg, Manitoba
R3H 1B5
Phone: 949-0533
Fax: 942-1428
WINNIPEG REGIONAL HEALTH AUTHORITY (WRHA) HOME CARE – AUTHORIZATION FOR SERVICES
Case Coordinator______________________
Office_________________________
Date Referral Sent_____________________
Urgent_________
Phone____________ Fax______________
ASAP________ Timeline_________ Regular___________
(dd/mm/yyyy)
Safe Visit Plan in Place: (If yes, please attach)
Yes
No
Care Plan Summary Attached:
Yes
No
Is the primary reason for referral related to a need for client and/or staff SAFE PATIENT HANDLING?
Yes
No
Comment: ________________________________________________________________________________
NON-WRHA GENERATED REFERRAL
Person Initiating Referral ___________________________________ Organization _______________________________________
Date __________________________
Phone _____________________________
Fax ______________________________
(dd/mm/yyyy)
CLIENT INFORMATION (if not included on label)
Last Name__________________________ First Name________________________ Date of Birth______________ Gender ____
(dd/mm/yyyy)
Address__________________________________ Phone______________ Client PHIN _______________ MHSC # ____________
(Include Postal Code)
Next of Kin/Contact ________________________ Phone ______________ Relationship to Client____________________________
Physician Name ____________________________ Address _______________________________________________________
CLIENT HEALTH INFORMATION
Diagnosis
1)
_
2) __
_____
Other conditions pertinent to therapy:
If client recently hospitalized, provide reason: ___________________________________ Date of Discharge: _______________
(dd/mm/yyyy)
SERVICES REQUESTED (Check all that apply)
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
TRANSFERS
PAIN MANAGEMENT
ACTIVITIES OF DAILY LIVING
REPOSITIONING
PASSIVE RANGE OF MOTION
PERSONAL CARE
MOBILITY
AMBULATION
FEEDING-SWALLOWING ASSESSMENT
WHEELCHAIR / SEATING
EXERCISES
COGNITIVE ASSESSMENT
SKIN/ULCER PREVENTION
OTHER________________________
COMMENTS
For Community Therapy Services use only:
DIAGNOSTIC CODES____, ____ SERVICE CODES ____, ____, ____, ____, ____TAKEN BY: ________ DATE_________ RE-OPEN_____ CROSS REFERRAL_____
Community Therapy Services Inc. Referral for Occupational Therapy/Physiotherapy – Approved January 4, 2011