204-475-0433 204-475-4011

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SAFE Living Manitoba Referral Form

There is a flat fee for this service of $400.00 CND to be paid at the time of assessment. Please note some extended health care insurance plans may cover occupational therapy services. The service includes a home-based cognitive, physical and functional screening, and a home access assessment for the purpose of determining SAFE Living Manitoba Risk Rating Score and to determine current functional status, appropriate residential options, potential supportive services, adapted equipment, and home modifications. Included in the price is a comprehensive report outlining the above findings and recommendations. 

 

You will receive a phone call from one of our occupational therapists within 2 business days, following the submission of this form. If you are having any trouble filling out this form, please do not hesitate to call us at 204-475-0433. Thank you!

REFERRER INFORMTION (IF NOT SELF-REFERRING)
REFFERRER INFORMATION (IF SELF-REFERRING)
RESIDENT INFORMATION
PAYMENT INFORMATION

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