Referral Form - Specialty Services

Please complete the form and forward with supporting documentation to Banyan Work Health Solutions Administrative Center by email at admin@banyanconsultants.com or via fax to 416-588-9235



Referral Source Information


Claimant Information


Employer Information


Claim Information


Referral Goals/Needs:


Services for Referral Choose one or more (For your convenience please refer to the appendix for a description of the services)

Specialty Services – Employability Services


Specialty Services – Physical Assessment Services


Specialty Services – Behavioural Services


Specialty Services – Work Place Facilitation


Specialty Services – Other


Referral Request Specifics (Claims Issues/Expectations/Desired Outcomes)


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