DriveFit Referral Form

Please complete all required fields below. If you have any questions about the Online Referral Form, please email us. Alternatively, please feel free to submit your DriveFit Referral Form using our PDF referral form.

* required fields

Client Information

Alternate Contact:

Services Requested

* Please choose at least one service

DriveFit In-Clinic
include DriveABLE* Evaluation
DriveFit On-Road
include DriveABLE* On-Road
DriveFit Virtual Screen

(*If cognitive concerns)

Driver anxiety
Post-Concussion
Post-Injury
Post medical event/surgery

 

Referred by:

Family physician
NP
Specialist
PT
OT
Self
Other

3rd Party Insurance (if applicable):

ICBC
WSBC
Other

Reason for referral:

Alzheimer’s or other dementia Parkinson’s Disease Multiple Sclerosis Other neurodegenerative disease Cardiac disease
CVA MI Surgery Brain injury/concussion Other Injury
SIMARD-MD /120
MoCA /30
Global Deterioration Scale: Stage

Symptom and Considerations (check all that apply):

Weakness:
Rt Leg
Lt leg
Rt arm
Lt arm
General
Paralysis:
Rt Leg
Lt leg
Rt arm
Lt arm
Amputation:
Rt Leg
Lt leg
Rt arm
Lt arm
Other motor impairment
Cognitive impairment
Visual impairment
Other sensory impairment

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