Make a Referral

Referrals to FunctionAbility can be made by anyone including families, hospitals, specialists, community healthcare providers and personal injury lawyers.

Once basic information is provided we will move expeditiously to meet with our clients whether at home or at a hospital prior to discharge.

Referrals can be made by phone by calling us at 1-877-260-0025 or online by filling out the form below.

Client Information

Client's Last Name:
First Name:
Middle Name:
Address:
City:
Postal Code:
Telephone No. (Home):
Telephone No. (Cell):
Date of Birth:
Gender: MaleFemale
E-Mail Address:

Referral Source Information

Referral Name:
Referral Email:
Name of Agency:
Telephone No:
Ext.:
Fax No.:
Is this Referral Source information the same as the Legal Representation? Yes

Insurance Information:

Name of Insurer:
Name of Adjuster:
Branch:
Claim Number
Date of Accident:
Telephone No:
Ext.:
Fax No.:
Is the client currently in the MIG? YesNo

Reason for Assessment:

Injuries:

Referral Requirements:

Assessment of Attendant Care Needs (Form 1)Assessment of Attendant Care Needs (Form 1) - In HospitalAssessment of Attendant Care Needs (Form 1) - In RetroAssessment of Attendant Care Needs - MedlegalOCF3 RequiredAssistive Devices AssessmentHome Safety/Accessibility AssessmentHousekeeping/Yard Maintenance AssessmentCaregiver AssessmentNeuro-Cognitive Functional AssessmentWorksite AssessmentReturn to Work AssessmentReturn to School AssessmentFuture Cost of Care ReportActivities of Normal Life AssessmentErgonomic AssessmentHand TherapySpeech Language Pathology - Cognitive-Communication AssessmentSpeech Language Pathology - Swallowing AssessmentSpeech Language Pathology - Peadiatric (articulation, fluency)

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