Referral Form - Specialty Services

Please complete the form and forward with supporting documentation to Banyan Work Health Solutions Administrative Center by email at or via fax to 416-588-9235

Referral Source Information

Claimant Information

Employer Information

Claim Information

Referral Goals/Needs:

Services for Referral Choose one or more (For your convenience please refer to the appendix for a description of the services)

Specialty Services – Employability Services

Specialty Services – Physical Assessment Services

Specialty Services – Behavioural Services

Specialty Services – Work Place Facilitation

Specialty Services – Other

Referral Request Specifics (Claims Issues/Expectations/Desired Outcomes)

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