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Workplace Rehabilitation and Health Referral Form

If you have any issues with this referral form or require more support, please contact us at or by calling 1800 000 677.

Worker Details

Interpreter required
Communication preferences or requirements
Access requirements

Referrer Details

Services Required

Service category

Claim Information and Diagnosis

Approved claim


Please provide a copy of any previous medical reports, certificate of capacity or any other relevant documentation, if available.

Click or drag files to this area to upload. You can upload up to 25 files.
Accepted file types: .xlxs, .jpg, .jpeg, .doc, .docx, .pdf, .png

Risks and Safety

Are there any court orders or legal proceedings applicable, e.g. child custody?
Has the participant ever been physically aggressive towards allied health, medical or support staff?
Has the participant been incarcerated in a prison, juvenile detention centre or spent time in a forensic hospital for a violent or sexual offence?
Is the participant currently engaging in alcohol or drug use?
Are there any known risks for visiting the participant in their own home?

Initial Assessment

Location of initial appointment
Are there any preferences for a consultant?
Appointment reminders

Service Agreement

Who will sign the service agreement

Payment Method

In addition to the payment provider, would you or another party like to receive the invoices?
Do you need a quote for service prior to proceeding?
Do you need a certain reference number or specific information on the invoice (e.g. PO number)

Further Information


Please note:  We endeavour to process referrals within 2 business days and will call you to schedule an appointment. If we are unable to make contact by telephone, we will schedule the appointment and email this to the contacts provided in this referral form. This email will confirm the appointment date and time, and any additional documentation or information required prior to the appointment. We would appreciate you looking out for this email and letting us know as early as possible if it needs to be rescheduled.

If your referral is urgent, please call us on 1800 000 677.