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 UK GDPR document: Healthywork Ltd Terms & Conditions June 2023 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 (If having used our services previously 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 the T & Cs) – email completed Referral 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 received and referrals can be cancelled at this stage if preferred or if the situation has changed.
Referral Documents – for All Referrals to Healthywork Ltd
All referrals must complete a Healthywork Referral Form: Referral Form 2023 – Healthywork Ltd
To open password protected documents, use the word: password
For completed confidential documents, reset with a new password if you wish to, otherwise the above password will remain.
]It is advisable to keep the Referral process completely transparent. It is preferable for the Individual Client/employee to be aware of what has been documented about them on the forms. E.g. the reason for Referral and the questions posed on the Referral form, which will be included and 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 client. This may be when they read the report or they can submit a Data Subject Access Request (DSAR).
Referrals/Reports – for those referrals including personal medical information
The individual client/employee should complete the Consent Form for any referral which will include personal confidential medical information. See: Individual Client Consent Form (1) for Healthywork input, access to medical records (optional) & Client read report prior to release UK GDPR updated June 2023
This will then be emailed by the Referrer with the completed Referral form.
This applies to the following services, as numbered on the Referral Form:
- Service 3B or 3D (Ergonomic Assessment F2F or Video call)
- Service 4 (Functional Capacity Evaluation)
- Service 5 (Cognitive Assessment)
- Service 6 (Mental Health/Neurodiversity Assessment)
- Service 7 (Career Re-direction Assessment)
- Service 9A (General Occupational Health/Occupational Therapy Assessment).
Physical Occupational Questionnaire (for Service 4 – FCE)
Physical Occupational Questionnaire – employee’s 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 or a list of the tasks, 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.
This Occupational Questionnaire and Job Description is not required if there is not a work role currently.
Cognitive Occupational Questionnaire (for Service 5)
Cognitive Occupational Questionnaire – employee’s Line Manager to complete.
Complete this questionnaire for a Cognitive 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 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 or a list of the tasks, 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 related documents/assessments that may be helpful.