Client Intake Form

Name:

Appointment Date:

Mr./Mrs./Miss:

Appointment Time:

Phone Number:

Age:

Accident Date:

Areas of Injury:

Job Title:

Employer:

Length of Employment:

Hourly Rate:

Weekly Hours:

Type of employment:

Current Work Status:

Attempt to RTW:

Pre–injury Modified

FAF form:

NEL or Pension Award:

Prior WSIB accidents or claims:

WSIB Retraining program:

Any other benefits (CPP) or source of income:

Any surgeries pertaining to the accident:

Undergoing any treatment:

Upcoming tests scheduled:

Last WSIB correspondence:

Latest WSIB Decision letter:

Other Ailments or any MVA:

Any representatives or Union on file:

Synopsis:

Xray’s taken:

Referral Source: