RT and Wellness Referral Form
Please answer the questions below to the best of your ability to refer a client for recreational therapy services with RT and Wellness. This information will be submitted to a secure, HIPAA compliant workspace.
Referring Person's Name
*
Referring Person's Phone Number
*
Referring Person's Email Address
*
Name of Individual Being Referred
*
Individual's Date of Birth
*
Individual's Address
*
Reason for Referral
*
Best Point of Contact Name
Please include who they are in relation to the Individual being referred.
Best Point of Contact Phone Number
Best Point of Contact Email Address
Support Coordinator Name & CSB
Support Coordinator Phone Number
Support Coordinator Email Address
What best describes the RT services the individual can benefit from (please select all that apply):
Increased knowledge and selection of leisure activities
Increased awareness of community locations, events and/or activities
Improved social skills
Improved coping strategies/emotion management resources
Improved self-worth, self-esteem and/or self-advocacy
Increased physical activity through recreation and leisure
Improved safety awareness in the community
Submit
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