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204-475-0433 info@enablingaccess.ca

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Adult Occupational Therapy Request For Service Form (New Client)

A. REQUESTER'S INFORMATION (Individual filling out this form)

Name:

Job Title (if applicable):

Company (if applicable):

Street Address:

City & Province:

Postal Code:

Email:

Phone:

B. CLIENT INFORMATION (Individual to receive OT service)

Client:

Same as Requester (skip to section C) Other (please complete the rest of this section)

Client Name :

Alternate Contact Name & Role (if applicable):

Client Street Address:

Client City & Province:

Client Postal Code:

Client Email :

Client Phone:

C. CLIENT MEDICAL INFORMATION

Client Date of Birth:

Diagnosis / Medical Info:

Current Weight (for equipment request forms):

Current Height (for equipment request forms):

9 Digit MB PHIN #:

NIHB #:

EIA # :

Service(s) Requested (Required):

PHYSICAL AND FUNCTIONAL ASSESSMENTS:

Permanent Impairment Assessment Wheelchair, Seating and Mobility Assessment Sensory Assessment and Consultation Functional Capacity Evaluations/Functional Abilities Evaluation Home-based Functional Assessment

HOME AND VEHICLE ACCESSIBILITY:

Home Modification Assessment and Consultation New Build Residential Accessibility and Inclusive Design Consultation

CONCUSSION / COGNITIVE REHAB:

Cognitive Assessment-BrainFX 360 Cognitive Functional Capacity/Functional Abilities Evaluations Post-Concussive Stay at Work and Return to Work Therapy Cognitive Work Conditioning

MENTAL HEALTH ASSESSMENT AND THERAPY:

Mental Health OT Assessment Progressive Goal Attainment Program Mental Health Therapy Mental Health Return to Work or Learn Coordination

WORKPLACE ASSESMENTS AND RTW COORDINATION:

Physical Demands Analysis/Cognitive Demands Analysis/Job Demands Analysis Worksite/Job Accommodation Individual Ergonomic Assessment Percentage of Duties Assessment Return to Work or Stay at Work Coordination

TRAINING:

Caregiver General Lift and Transfer Training Caregiver Individual-Specific Transfer Training

MEDICAL-LEGAL SERVICES:

Medical-Legal Cost of Future Care Assessment Medical-Legal Occupational Therapy Expert Opinion

OTHER:

D. REPORT INFORMATION

Report:

Send to Client (skip the section E) Send to Requester (skip to section E) Other (please complete the rest of this section)

Foward Report to Name:

Forward Report to Email:

E. BILLING INFORMATION

Billing:

Send to Client (skip to section F) Send to Requester (skip to section F) Other (please complete the rest of this section)

Bill to Name:

Bill to Company:

Bill to Street Address:

Bill to City & Province:

Bill to Postal Code:

Bill to Email:

F. OTHER

Do you agree to receive email communication regarding our servces and related research or news?:

Yes No

How did you find us?:

Other:

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Have questions? Fill out an Inquiry Form

Give us a call at 204-475-0433

Email us at info@enablingaccess.ca

Visit us at 1431 Corydon Avenue, Winnipeg, MB Canada

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