Work Able Online Referral Form

Please use the form below for ON-LINE referrals only.

If you prefer to fax the referral, please download the MS Word or Adobe acrobat PDF referral form. Once completed, fax to one of the fax numbers listed in the form.

Alternately, you may contact a specific Work Able location directly by telephone and make your referral.

North York Fax (416) 490-0506
Mississauga Fax (905) 306-0519
Barrie Fax (705) 727-1672
Halifax Fax (902) 450-1458

On-line Referral Form
Referral Source Information	NEW REFERRAL
Please fill in this form and tell us a few important facts about your referral. A Work Able Client Services representative will contact you to confirm the information you sent to us

* denotes required fields
* First Name:
* Last Name:
Company:
* Address:
* City:
* Province:
* Postal Code:
Country:	Canada
* Phone:	-
Fax:	-

Category:
Which best describes you?*

In the interest of claimant's confidentiality, it is important that you provide a correct email address. A confirmation of this referral will be sent to this email address:

* Email Address:

* Confirm Email:

Claimant / Insured Information


* First Name:
* Last Name:
* Gender:	Male Female
* Address:
* City:
* Province:
* Postal Code:
Country:	Canada
* Phone:	-
Claim Number:
Occupation:
Require transport?:	Yes No


Date of Birth:
Date of Injury:
Translator:	Yes No
Language:
Nature of Injury/Diagnosis:

Question to Assessor:

Assessment Information

* Choices:
Orthopaedic IE
Physiatry IE
Neurological IE
FAE
3/5 Day FAE
CAT IE Assessment
Psychological Assessment
PsychoVocational or NeuroVocational Evaluation
Work Site Ergonomic Consultation
Work Conditioning/Hardening Program
Comprehensive Work Conditioning/Hardening Program
Work Strategy Program
Other

please specify:

Appointment timeframe?	0-2 weeks 2-4 weeks
In addition to yourself, who should be notified of the assessment?	Claimant/Insured Legal Representative Other please specify:
In addition to yourself, who should receive a copy of the report?	Claimant/Insured Legal Representative Other please specify:

Other

Send invoice to

	Same as Referrer
First Name:
Last Name:
Company:
Address:
City:
Province:
Postal:
Country:	Canada
Phone:	-
Fax:	-
E-Mail:

Claimant/Insured’s Legal Representative


First Name:
Last Name:
Company:
Address:
City:
Province:
Postal:
Country:	Canada
Phone:	-
Fax:	-
E-Mail:

Comments / Attachments

Do you have any questions or comments for us?

Attachment (one file only):

Multiple attachments should be sent via email to clientservices@workable.ca

Please send all medical documentation to:
Work Able
4 Lansing Square, Suite 110
North York, Ontario
M2J 5A2