WHSM

Referral Form

EMPLOYEE DETAILS

Name:
Phone:
Mobile:
Address:
Date of Birth:
Interpreter needed:
Claim No:
Insurer:
Insurer Contact:
Insurer Phone:
Date of Injury:
Injury:

EMPLOYER DETAILS

Employer:
Phone:
Mobile:
Address:
Employer Contact:
Fax:
Email:

TREATING DOCTOR DETAILS

Name:
Email:
Address:
Phone:
Fax:
When faxing or emailing,please attach a medical certificate
 

INJURY MANAGEMENT SERVICES REQUIRED (please tick)

Initial Needs Assessment
Assessment of Functional Abilities
Evaluation of Workplace
Assessment of Vocational Redirection Options
Develop Return To Work plan
Activities of Daily Living Assessment
Assessment of Workstation Ergonomics
Rehabilitation Counselling to facilitate RTW
Home Office Assessment
Psychological intervention (e.g.conflict resolution)
 

SPECIALISED SERVICES REQUIRED (please tick)

Health and Wellbeing Workshop
Aged Care / Home and ADL Assessment
Risk Assessment / Gap Analysis
Medico-legal Assessment
WHSTraining (manual handling, functional education)
Task Analysis
 
 Comments:
  Referred by:
  Contact No:
  Signature:
  Date:

WORK HEALTH SAFETY MATTERS
Suite 204 | 460 Pacific Highway | St Leonards NSW 2065
Ph: 02 9929 0133 | Fax: 02 9929 3999
E-mail:office@whsm.com.au | www.whsm.com.au