Blue Light SGPT Referral Form
Bridge the Gap Between Physical Therapy and Full Fitness
Client Name
First Name
Last Name
Client Phone Number
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Partner
Referrer
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
What Phase is the Client In?
Cleared from PT
Concurrent with PT
General Functional Care (Not injury related)
Has the Client been cleared for progressive strength training?
Yes
Yes, with modifications
Not Yet
List any movement restrictions, contraindications, or red flags:
Areas to focus on strengthening or mobility:
Any activities you specifically recommend avoiding:
What’s the primary goal for this client?
Build basic strength and movement confidence
Improve conditioning and endurance
Transition safely from rehab to general fitness
Restoring and reinforcing functional movement patterns
Other
Would you like progress updates?
Yes: Midpoint & End-of-Program Summary
Yes: Contact me if any red flags arise
No updates needed
Client has consented to provide us information regarding continuation of care.
Yes
Other
HIPAA Compliance Notice: This form is HIPAA compliant and does not request Protected Health Information (PHI). If it is necessary to share PHI, please contact us so we can provide our secure, encrypted email portal.
No PHI
I need to send PHI, please send me an encrypted email for HIPAA information.
Authorization
Continue
Continue
Should be Empty: