OVRS REFERRAL FORM
Date
*
/
Month
/
Day
Year
Date
OVRS Branch
VRC Name
VRC Email
example@example.com
VRC Phone
Please list the one you are most likely to answer
CLIENT INFORMATION
Who is being referred for Occupational Therapy at Recreate Pathways?
Client Legal Name
*
Client Preferred Name (if different)
Client Pronouns
Please Select
he/him/his
she/her/hers
they/them/theirs
she/they
he/they
Other
Not Sure
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Client DOB
*
.
Month
.
Day
Year
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Why are you referring to Occupational Therapy? What are the barriers your client is experiencing to employment?
*
This can help us better understand what services your client may need and how we can be of support toward meeting employment goals.
Has the client received any formal diagnosis? Please list them here including level of Autism if applicable
*
Formal diagnosis are not needed to initiate services but they do help us understand your clients needs better
REQUESTED SERVICES
Let us know what services you are interested in and how you would like to access those services
Select all areas that you are seeking support in
*
Sensory Processing
Emotional Regulation
Interpersonal Problem Solving
Daily Routines
Weekly Scheduling
Career Exploration
Occupational Therapy Evaluation
Accommodations
Other
This is a HIPPA compliant form and platform that is more secure than e-mailing or faxing. If you would like to include any files such as previous evaluations or ROIs, anything that you would like to us to see, you can securely upload them here and we will receive them.
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