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 Healthywork Ltd Terms & Conditions 2024 which includes our UK GDPR document 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 or 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.
Referrals to Healthywork Ltd – without personal medical information on the Referral Form:
When no medical information is being detailed – eg cases where groups of individuals will be assessed – DSE prevention assessment *Service 1, 2), non complex Ergonomic assessments (Service 3A, 3C, 3D1) All referrals must complete the Healthywork Referral Form: Referral Form 2024 – Healthywork Ltd
To open password protected documents, use the word: password
For completed 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 Referral form. 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).
Referral which include personal medical information on the Referral Form and need to share other health documents:
Please follow this process document for these services: Healthywork Ltd Referral Process for Complex Ergonomic, Mental Health or Neurodiversity, FCE, Cognitive Assessment 2024
The individual client/employee should first complete the Individual Client Consent Form (1) for Healthywork Ltd, May 2024 for any referral which will include personal confidential medical information to be included on/with the completed Referral Form 2024 – Healthywork Ltd
To open both password protected documents, use the word: password
For completed documents, reset with a new password if you wish to, otherwise the above password will remain.
This completed Individual Client Consent form (1) should 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 3D2 (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 Job Demands Questionnaire (for Service 4 – Functional Capacity Evaluation)
Healthywork Physical Job Demands Questionnaire – 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 Job Demands Questionnaire (for Service 5 – Cognitive Assessment)
Healthywork Cognitive Job Demands Questionnaire – 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 health and work related documents/assessments that may be helpful.