Referral Forms
These forms are periodically modified. To make sure you are using the most current version, please download it from this webpage.
NOTE: For all referrals (excluding referrals to ABI rehab), please fax referral forms directly to the programs being requested. Program details and contact information can be found through Rehab Finder.
| Outpatient Rehab Programs for COVID-19 | |
| RCA Post-COVID-19 Outpatient Rehab Referral Form (February 2022) | A standardized, streamlined post-COVID-19 outpatient rehab referral form. |
| Referrals to Inpatient Rehab/CCC | |
| Acquired Brain Injury Rehab Referral | Use this link to access the referral form and instructions for where to fax the completed referral form for ABI inpatient rehab. |
| GTA Rehab Network Integrated Acute Care to Bedded Levels of Rehabilitative Care & CCC Referral Form (Feb 2021) | Use this form for referrals to inpatient (bedded) rehab/CCC programs provided by member organizations of the GTA Rehab Network. The form includes referral information pertinent to COVID-19 (Note: Not used for stroke patients.)
NOTE: Fax completed referrals directly to the program/service you are requesting as per the organization’s intake process. Information on the application process is available on Rehab Finder. For details on completing form, see Reference Guide for Inpatient Rehab/CCC Referrals. |
| GTA Rehab Network Supplemental Referral Information Form (Feb 2021) | This form is an abridged version of the form above. Use this form to provide updates on patients that have already been referred. (Note: Not used for stroke patients.) For details on completing form, see Reference Guide for Inpatient Rehab/CCC Referrals. |
| eStroke Inpatient Rehab Referral Form (Rev. Mar 2023) | Use this form for stroke referrals for organizations that do not have access to the eStroke Rehab Referral System. |
| Referrals to Outpatient/Ambulatory Rehab |
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| Acquired Brain Injury Outpatient Rehab Referral Form | Use this link to access the referral form and instructions for outpatient and community-based referrals. |
| Outpatient/Ambulatory Rehab Referral (PDF) (Rev. June 2019)
Outpatient/Ambulatory Rehab Referral (Fillable) (Rev. June 2019) |
Use this form for all rehab populations except total joint replacements and acquired brain injury. (See separate sections for instructions on these populations.) The form may be completed online, printed and faxed OR printed, completed by hand and faxed. |
| E-Stroke Outpatient Rehab Referral Form (Rev. Nov 2015) | Use this form for stroke referrals from acute care organizations that do not have access to the E-Stroke Rehab Referral System. |
| Outpatient Referrals for Hip, Knee & Shoulder Replacement/Revision | |
| Outpatient Rehab Referral for Hip, Knee or Shoulder Surgery (PDF) (March 2023)
Outpatient Rehab Referral for Hip, Knee or Shoulder Surgery (Fillable) (March 2023) |
Use this outpatient rehab referral form for hip, knee and shoulder replacement or revision provided by member organizations of the GTA Rehab Network. |
| Listing of Outpatient Rehab Programs that Accept Hip, Knee or Shoulder Surgery External Referrals (May 2023) | This comprehensive listing identifies outpatient rehab programs across the GTA that will accept external referrals for outpatient rehab following hip, knee and shoulder replacement or revision. |
| TJR Outpatient Rehab Follow-Up Form (June 2014) | Use this form to support the communication between the outpatient rehabilitation physiotherapist and the client’s orthopaedic surgeon. |
