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Clinical
Contact
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Medico Legal Assessment - New Referral
Injured Person's Information
*
Indicates required field
Name
*
First
Last
Your Ref:
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
Mobile Phone Number
*
Date of Birth
*
Injury/Disability
*
Date of Injury
*
Basic Information
*
Can the injured person walk?
Are they non-speaking?
Do they use a wheelchair?
Will an interpreter be required?
Are the there behavioural issues?
It is expected that the law firm arrange an interpreter if required. A longer assessment time is required if the assessment is conducted through an interpreter.
It is expected that the law firm arrange an interpreter if required.
A longer assessment time is required if the assessment is conducted through an interpreter.
Litigation Guardian/Client (if applicable)
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Law Firm Details
Law Firm
*
Office
*
Lawyer
*
First
Last
Assistant
*
First
Last
Lawyer Email
*
Assistant Email
*
Direct Line
*
Service(s) Required
Tick as relevant
*
Occupational Therapy
Neuropsychology
Physiotherapy
Case Management
Speech Pathology
Building Assessment
Vocational Assessment
Day in the Life Video
Psychology
Assessments are usually scheduled 2-3 months ahead. Reports are usually completed 6-8 weeks from assessment.
Assessments are usually scheduled 2-3 months ahead.
Reports are usually completed 6-8 weeks from assessment.
Funding & Scheduling Information
Do you require a quote?
*
Yes
No
Does the client have preferred days/times for assessment?
*
No
Yes (please detail below)
Preferred days/times
*
Do you require an urgent assessment and/or report? (e.g. upcoming court dates and you require the assessment and report within 4 weeks)
*
Yes - an uplift fee will apply
No
We thank you for your referral and will be in touch shortly. Once confirmed, please ensure any relevant and important court dates are conveyed in your letter of instruction to assist us to meet your needs.
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