Refer to Active Working Solutions

ONLINE REFERRAL FORM: Please fill in the referral form below, and submit this form online.

PRINT VERSION: A pdf AWS referral form and AWS Doctors referral form is also available. Please print out this form and post with any additional information to: Active Working Solutions Head Office PO Box 854, Campbelltown NSW Australia 2560 or fax toll free to: 1300 132 991.

SERVICES REQUIRED:
Approval is hereby given to Active Working Solutions to undertake the specified services: WorkCover, Comcare or CTP Case Management Vocational Assessment / Job Placement Critical Incident Stress Debriefing (CISD) Work Conditioning / Exercise Program Psychological Assessment Driving Assessment / Training Pre-Employment Screening / Drug & Alcohol Testing Work Conditioning / Exercise Program / WRAP OHS Consultancy (Audit / Training) Section 40 Assessment / Medico legal Assessment Functional Capacity Assessment Occupational Therapy Services / Assessment Workplace Assessment General Counselling Enhanced Primary Care   Training Services (please nominate here):   Nominate Training required here if applicable. Other Services / Additional Comments:   Enter additional information here if applicable.
WORKER'S DETAILS
First Name
Surname
Claim No. (if applicable)
Address
City
Postcode
State	NSW QLD VIC NT WA SA
Occupation
Phone (Home)
Phone (Work)
Email Address
Date of Birth	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 /
Interpreter Required	Yes No
Language Required
Date of Injury	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 /
Type of Injury
If worker is currently at work	Normal Duties Suitable Duties
Date ceased if worker if currently off work	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 /
Nominated Treating Doctor
Phone (Work)
Fax (Work)
Address
City
Postcode
State	NSW QLD VIC NT WA SA
EMPLOYER DETAILS
Business Name
Contact First Name
Surname
Title
Address
City
Postcode
State	NSW QLD VIC NT WA SA
Phone (Work)
Fax (Work)
Email Address
INSURER / FUNDING DETAILS
Insurer
Contact First Name
Surname
Title
Address
City
Postcode
State	NSW QLD VIC NT WA SA
Phone (Work)
Fax (Work)
Email Address
Liability Accepted	Yes No Don't Know
Comments	Enter additional information here if applicable.
Attachments	Claim Forms Medical Certificate Reports Other
REFERRER DETAILS
Referral Date	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 /
First Name
Surname
Title
Business Name (If applicable)
Phone (Work)
Fax (Work)
Email Address