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Health2Work Referral Form
Questions for Participants to Determine Fit for Health2Work Program
Is the participant at a contemplative stage of change or higher in regard to employment plan?
Yes
No
Is the participant considering any of the following:
Training (please specify below)
Education (please specify below)
Start/return/maintain work (please specify below)
Please specify here, including details on the Job (Re) Training/Employment Plan related to this Health2Work Referral
Is the participant interested in (re) training/employment opportunities but has any of the below:
Back Pain
Yes
No
Neck Pain
Yes
No
Strains and sprains
Yes
No
Shoulder pain
Yes
No
Headache
Yes
No
Whiplash
Yes
No
Participant Information
Member ID:
First Name
Last Name
Phone:
Date of Birth:
Email Address:
Address:
Language Preference:
Preferred Method of Contact:
Support Needed (ie. ESL, Mobility etc.):
Area of Illness / Injury
Referrer:
Caseworker
Community Agency Staff
Employment Facilitator
Physician or Nurse Practitioner
Other
Referral Source 1
Referrer Name:
Referrer Organization Name:
Referrer Phone:
Referrer Fax:
Referrer Email:
Referral Source 2
Referrer Name:
Referrer Organization Name:
Referrer Phone:
Referrer Fax:
Referrer Email:
Additional Information
Does the participant require transportation assistance to get to appointments?
Yes
No
Are interpretation services required?
Yes
No
Does the participant have reliable childcare arrangements so they can attend appointments?
Yes
No
N/A
Would the participant be able to participate in chiropractic care such as: Education and coping strategies, home exercises, gentle exercise, soft tissue therapy, joint mobilization or adjustments:
Yes
No
Are there people in the participant's life who will support them while they're enrolled in this program?
Yes
No
Gender Preference for Chiropractor?
No preference
Male
Female
Is there any other important information the chiropractor should know?
In which city would the participant like/prefer to attend this program?
Waterloo
Kitchener
Cambridge
Was verbal consent given by the client?
Yes
Verbal consent was given by the client on this date:
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