Make a Referral

The type of community based rehabilitation service(s) that you are requesting *

Choose one or more services

Occupational Therapy (OT)

Active Rehab ~ Kinesiologist (AR)

Rehabilitation Assistant (RA)

Clinical Counselling (RCC)

Is your service request going to be for telehealth or in-person therapy? *

Indicated which service request you currently need (check all the apply)

Telehealth services

In-person Therapy

Both Telehealth and In-person services

Referrer name *

First Name

Last Name

Referrer phone number

Please enter the best number to reach you at

(###)

###

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Client name *

First Name

Last Name

Client current address

Please provide us with your client's full address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client phone number

Please enter the best number to reach your client

(###)

###

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Client's date of loss

The client's date of loss (DOL)

MM

DD

YYYY

Client's date of birth

The client's date of birth (DOB)

MM

DD

YYYY

Current coverage *

Does the client currently have coverage? Please select one only

ICBC

WorkSafe BC

Group Health Insurance Plan

Lawyer

Paying Privately (no coverage)