Neil Squire Solutions Referral Form

Neil Squire Solutions carries out Ergonomics and Assistive Technology assessments on a fee-for-service basis. Assessments are carried out by Occupational Therapists and Assistive Technology Specialists.

If you have any questions about this form or would like immediate assistance, please contact us:

Telephone: 604 473 9360

Toll Free: 1 877 673 4636

solutions@neilsquire.ca

Client Information

First Name

Last Name

Date of Birth

Gender

Pronouns

Address

Telephone

Alternative Telephone

Current Status

EmployedUnemployed Full-time student

Employer Name

Job Title

Work Address

Do you work from home, from an office, or both?

Work from homeWork from an officeWork from home and from an office

Do you have any open insurance claims? (i.e., WorkSafeBC, ICBC, long term disability)

YesNo

Provider

Do you have an open case with WorkBC Employment Services?

YesNo

WorkBC Centre

Services Requested

Ergonomic Workstation AssesmentAssistive Technology Assessment Computer Training Services (basic computer, assistive technology training)

Reason for referral

Goal of assessment

Type of Computer

Referral Source and Billing Information

ICBC	WorkSafe BC	WorkBC	Extended Health Benefits	Employer
Private Pay	Other

Name of referral source

Name of Referral Organization

Claim #

Telephone

Please attach any relevant documents such as doctor's notes or previous assessment reports that may provide important background medical information about the client:

Contact Information