Referral Documents – downloadable

Referral documents are available below, depending on the Occupational Health Service you require.

See our Services Page for each type of service we offer. We can also provide a combination of  one or more services.

All referrers should refer to our T & C and Individual GDPR document: Healthywork Ltd Terms & Conditions 2020 as a pre-requisite to referral.

Healthywork Services

If you know what service you require and want to go ahead with us please complete the relevant documents below. (Having used our services previously and you do not require an initial estimate/quotation). We will keep a time sheet of the input provided (hours/minutes and travel package/costs) and invoice accordingly, as per our hourly rates  – see Healthywork Ltd Terms & Conditions 2020.

Email completed forms to alison@healthywork.org.uk

Otherwise for complex cases, new referrers, multiple services, Contact us to outline the situation and we will provide a written quotation.

We can clarify estimated costs after completed forms are recieved and referrals can be cancelled at this stage if preferred or if the situation has changed (seesee Healthywork Ltd Terms & Conditions 2020).

Referral Documents – for All Referrals to Healthywork

All referrals must complete a Healthywork Referral Form: Referral Form 2020 GDPR

To open password protected documents, use the word: password 

On completed confidential documents, reset with a new password if you wish to, otherwise the above password will remain.

We advice to keep the Referral process transparent. It is preferable for the individual to be aware of what has been documented about them on the forms. Eg the reason for Referral and the questions posed on the Referral form, which will be answered in the report.

Please be mindful when completing referral documents and in all written correspondence, incl emails, that all parties may read the information, including the individual. This may be when they read the report or they can submit a Data Subject Access Request (DSAR).

Reports including personal medical information

The Healthywork Consent Form is required for any assessments reports which will include personal confidential medical information. This applies to the following services, as numbered on the Referral Form:

  • Service 3B (Ergonomic Assessment)
  • Service 4 (Functional Capacity Evaluation)
  • Service 5 (Cognitive Assessment)
  • Service 6 (Mental Health Assessment)
  • Service 7 (Career Re-direction Assessment)
  • Service 9A (General Occupational Health/Occupational Therapy Assessment).

The individual client should complete the Consent Form: Individual Client Consent for access to medical records & Client read report prior to release GDPR March 2020

Physical Occupational Questionnaire (for Service 4 – FCE)

Physical Occupational Questionnaire – employee Line Manager to complete

Complete this questionnaire for a Functional Capacity Evaluation (Service 4 on the Referral Form). To detail the physical aspects of the existing job that the individual conducts currently or is due to conduct, if suitable.

Please complete the Physical Occupational Questionnaire in as much detail as possible. If there are multiple tasks, provide a document with additional detail. This will help to reduce the time required to review the work tasks on site.

Also, send the Job Description, so we have details about the job demands/tasks which we are assessing individual’s abilities against.

The assessment will then conclude if there is a job match between the individual’s physical abilities and the physical demands of the job. This is not required if there is not a role currently.

Cognitive/Psychological Occupational Questionnaire (for Service 5)

Cognitive & Psychological Occupational Questionnaire – employee Line Manager to complete

Complete this questionnaire for a Cognitive/psychological Assessment (Service 5 on the Referral Form). To detail the cognitive demands of the existing job that the individual conducts currently or is due to conduct, if suitable.

Please complete the Cognitive/psychological Occupational Questionnaire in as much detail as possible and provide as much detail about the individual tasks performed as possible, as this will help to reduce the time required to review the work tasks on site.

Also, send the Job Description, so we have details about the job demands/tasks which we are assessing individual’s abilities against.

The assessment will then conclude if there are any cognitive difficulties and suggest reasonable adjustments if it is likely that they can continue to perform all or some of the tasks.  This is not required if there is not a role currently.

In addition to the Referral documents above, please send us any relevant work documents, that may be helpful.