DeSantis Occupational Therapy Services

Serving Hamilton, Burlington, Stoney Creek & St. Catharines 

Phone: 905-902-7097

 

Referral Form

Referral Form

Thank you for your interest in DeSantis Occupational Therapy Services.

Please use the form below to refer yourself or your client.

If you are having problems with the form, or you would prefer not to use the online version, please contact D.O.T.S. to start the referral process.

Client's First Name:
 Client's Last Name:  
Male or Female:
 Date of Birth (e.g. Jan 1/10):  
 Client's Phone:  
Client's Address
(please include postal code):
Date of Accident:
Accident Details:
Impairments/Disability:
Catastrophic Designation:
Insurance Company Name
(and Branch or City):
Insurance Company's Address:
Adjuster's Name:
Adjuster's Telephone:
Adjuster's Fax:
Claim Number:
Policy Number:
Referral Source Full Name:
Referral Source Email:
Referral Source Phone:
Referral Source Fax:
Referral Source File Number:
 Will a medical brief follow? Yes       No
Which services are you requesting? 

Future Care Needs and Cost Analysis / Life Care Plan
Medical-Legal Assessment
Occupational Therapy In-Home Assessment 
Attendant Care Assessment
Cognitive Assessment

Occupational Therapy
Hospital Discharge Planning
Job Site Analysis / Ergonomic Assessment / Physical Demands Analysis 

Walker Assessment by an Assistive Devices Program (ADP) Authorizer
Manual Wheelchair Assessment by an Assistive Devices Program (ADP) Authorizer
Power Wheelchair Assessment by an Assistive Devices Program (ADP) Authorizer

Cushion & Backrest Assessment
by an Assistive Devices Program (ADP) Authorizer
Printing / Handwriting / Fine Motor Skills Assessment and Treatment

Additional Information/Comments:
Referral Source Full Address (include firm/company name):
   By checking this box, you consent to the terms and conditions.
All information will remain confidential.
 

  
           
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