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Re:Function Referral – Rehabilitation Services

How can we help?

Required boxes are indicated with *

Referral Source Information

I am inquiring about?

* CM/Employer Contact Name

* CM/Employer Contact Phone #

CM/Employer Contact Fax #

* CM/Employer Contact Email

* Company/Organization



Postal Code

Assistant’s Name

Assistant’s Email

* Confirmation email to be sent to

Client Info Section

* Client Name

* Date of Birth

Client Phone #

Client Email

Client Address


Postal Code

Policy No.

Client ID No.

Date of Injury

Is an Interpreter Required?

Language Required

Diagnosis/Medical Concerns

Gender of the Client

Extra Info Section

Client is aware of Referral?

How did you hear about us?

Additional Comments

Exceptional People.

Exceptional Service.

Function is our Focus