Celebrating 10 years, 2010-2020

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REFERRAL REQUEST
Fields marked with an * are required

SERVICE REQUESTED (This section is mandatory)

CLAIMANT / CLIENT INFORMATION
Gender *
Date of Birth *
Is the Claimant aware of the purpose of this referral? *
Are they aware that a Metrics Vocational Rehab Consultant will be contacting them *

CLAIM DETAILS
Date of Disability *
Change of Definition
Max Benefit Date

EMPLOYMENT DETAILS

Complete this section for RTW OWN OCCUPATION goal
Have you included a job description, PDA or CDA with the referral?

Complete this section for RTW ALTERNATE OCCUPATION goal
Have you included a resume?

MEDICAL DETAILS
Have you included medical with the referral? *

ADDITIONAL DETAILS

If you prefer you can download this fillable PDF form and email it to us at rehab@metricsvocational.ca or fax it to us at 905-951-7582

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