OCCUPATIONAL THERAPY REFERRAL FORM Patient name: DOB

Phone: (323) 442-3340 | Fax: (323) 442-3351 | ot[email protected]

Health Sciences Campus: 1640 Marengo Street, Suite 500, Los Angeles, CA 90033

University Park Campus: 1031 W. 34

TH

Street, Suite 452, Los Angeles, CA 90007

Downtown Los Angeles: 830 S. Flower Street, Los Angeles, CA 90017

OCCUPATIONAL THERAPY REFERRAL FORM

Patient name: DOB: Phone: _________________________

Address: _

Diagnosis: ICD-10: ________________________

History/Precautions: _

Physician’s Name/Title: Phone:_________________________

Phone/Address: ______________________________________________________________________________

Email: NPI #: _________________________

 OCCUPATIONAL THERAPY EVALUATION AND TREATMENT

 OCCUPATIONAL THERAPY EVALUATION AND REPORT (no treatment included)

 HOME and/or WORK EVALUATION (Safety, Adaptive Equipment, Ergonomics)

Lifestyle Redesign

®

is the development and enactment of health-promoting habits and routines designed to

improve health and quality of life and prevent and control chronic health conditions.

Please select one or more Lifestyle Redesign

®

program(s):

 Weight Management

 Diabetes Management

 Chronic Pain Management

 Fibromyalgia

 Chronic Headaches

 Behavioral Health

 Smoking Cessation and Relapse Prevention

 Movement Disorders / Parkinson’s Disease

 Multiple Sclerosis

 College Student

 Oncology

 Lifestyle Risk Assessment

 Autism Spectrum Disorder/Asperger’s

 Epilepsy

By signing below I certify that I have examined the patient and that services will be furnished while the patient is under my care, and that the plan is established and will be

reviewed every 90 days or more often if the patient’s condition requires.

_________________________________________________

PHYSICIAN’S SIGNATURE DATE