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Services
About Us
Our Team
Collaborators
Resources
Referral Form
Contact Us
FAQs

Referral Form

THE GOOD WORK LAB REFERRAL

Please contact us with any questions you may have. The Good Work Lab Team is standing by to assist.

Contact Us

Thank you for your referral.

CLIENT DETAILS

First

Last

Client's Name

Claim No

Client's Phone

Client's Mobile

Client's Location

REFERRER DETAILS (if applicable)

Referrer's Name

Referrer's Address

Referrer's Phone

Referrer's Fax

Referrer's Email

Date of Referral

EMPLOYER DETAILS (if applicable)

Employer's Name

Employer's Address

Employer's Contact Person

Employer's Phone

Employer's Fax

Employer's Email

TREATING PRACTITIONER

Practitioner's Name

Practitioner's Address

Practitioner's Phone

Practitioner's Fax

SPECIALIST DETAILS

Specialist's Name

Specialist's Address

Specialist's Phone

Fax

EMPLOYMENT DETAILS

At Work, Same Pre-injury Hours
At Work, Less Pre-injury Hours
Not at Work - Able to return to Position
Not at Work - Unable to return to Position
Terminated

PRE-INJURY HOURS (hours worked per week)

Full-Time
Part-Time
Casual

SERVICES REQUIRED

Injury Prevention Services
Collaborative Research
Ergonomic Assessment
Initial Rehabilitation Assessment
Functional Capacity Evaluation
Worksite Assessment
Suitable Duties Program
Host Worksite Assessment
Host Suitable Duties Program

I would like The Good Work Lab to:

Contact the client directly and commence services as requested.
Contact me to discuss further prior to commencement.

OTHER RELEVANT INFORMATION

About us

We diagnose organisational issues and collaborate to design solutions to reach your organisational potential using science and design.

Services

Collaborative Research
Good Work Design
Occupational Rehabilitation Services

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