SAFE Living Manitoba Referral Form

There is a flat fee for this service of $350.00 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 functional screening, and a home access assessment for the purpose of determining 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, recommendations, and resources. 

 

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