WorkCover Referral: Adjustment to Injury Counselling
Submit a referral for counselling support following a workplace injury.
Referrer's Full Name
*
First Name
Last Name
Referring Organization
*
Referrer's Position
Referrer's Email Address
*
example@example.com
Referrer's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Full Name
*
First Name
Last Name
Client's Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email Address
example@example.com
WorkCover Claim Number
*
Date of Injury
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Injury
*
Reason for Referral / Presenting Issues
*
Adjustment to injury
Anxiety/stress management
Coping with pain
Reduced confidence
Return-to-work support
Workplace adjustment
Sleep difficulties
Other
Additional Comments or Relevant Information
Supporting Documents
Upload Files
Drag and drop files here
Choose a file
Upload any supporting documents for this referral.
Cancel
of
Select the supporting document types you will upload
Referral letter
Medical certificate
Work capacity certificate
Referral report
Other
Consent: I confirm that the client has consented to this referral.
*
Yes, consent has been obtained.
Submit Referral
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