Outpatient Occupational Therapy referral

Outpatient Occupational Therapy Referral – Introduction

Sasha Prinsloo Occupational Therapy Inc. offers outpatient occupational therapy services at our Tokai and Somerset West practices. Our outpatient services focus on adult rehabilitation, return-to-work facilitation, functional independence, and participation in meaningful daily occupations, following a comprehensive, person-centred assessment.

This referral form assists our team in allocating the most appropriate therapist and ensuring timely initiation of outpatient services.

Outpatient Department Managers:

Tokai Outpatient Practice

Rose Endley – Outpatient OT Manager
Email: rose@tokaiot.co.za
Contact number: 087 138 4081

Somerset West Outpatient Practice

Laura Jacobs – Outpatient OT Manager
Email: laura@somersetot.co.za
Contact number: 087 138 4081

Should you have any questions regarding referrals, service suitability, or availability, please contact the relevant Outpatient Manager.

Kind regards

Sasha Prinsloo

sashaprinsloo-ot.co.za

Please select the preferred location for the outpatients service to occur:*

Tokai OT, Faircape Health Tokai EstateSomerset OT, Faircape Health Somerset West

Patient information *

First NameLast Name

Date of Birth*

Date

Contact details of patient / NOK*

Please enter a valid phone number.

Reason for referral*

Occupational Therapy service required

Physical rehabilitationVocational rehabilitationNeurological rehabilitationCognitive assessment and rehabilitationADL training including appropriate assistive device recommendationHand therapyHome safety assessment and modifications

How did you/the patient get referred?*

HCP referralSelf referralOther

Name*

First NameLast Name

Profession

Phone Number*

Please enter a valid phone number.

Signature*

Outpatient Occupational Therapy referral

Referrer details