Make a referral

Select Referral Type

Management Referral

Complete referral process with triage analysis, detailed questions, and appointment booking. Includes 6 stages for comprehensive case management.

Wellbeing Referral

Streamlined referral process for wellbeing assessments. Includes employee confirmation and specific wellbeing questions. 2-stage process.

About the Employee

Please review the employee information and answer the questions below.

Employee Details

Name: Sarah Johnson

Date of Birth: 15/03/1985

Job Title: Senior Software Developer, IT Department

Employee ID: EMP001234

Work Location: London Office

Length of Service: 2-5 years

Line Manager: Michael Brown

Email

sarah.johnson@company.com

Used for confirmations and notifications

Phone

+44 7700 900123

For booking updates and follow-ups

Has employee been advised a referral is being arranged?

Yes

No

Is the employee a shift worker?

Yes

No

Is the employee in work currently?

Yes

No

First Date of absence

Reason for Referral

Short Term Absence

(Frequent or sporadic sickness please provide details below)

Long Term Absence

(Likely to trigger client absence policy)

Presenteeism

(In work - not on full duties due to known reasonable adjustments or workplace adaptations)

Follow up review

(Employee needs a further consultation)

Fit4jobs review

(Fit4jobs Referral)

Note: Pre-set options with additional fields can be edited in the form customisation, so it'll appear on all forms for managers and thus reported upon via MI.

Reason Comments

Additional Referral Information

Free Text Notes

Upload Attachments

Upload supporting documents PDF, DOC, DOCX up to 10MB each

Service Required

Do you require a pre consultation briefing with our clinician?

Yes No

Do you require a post consultation briefing with our clinician?

Yes No

Manager's contact number

Referral Questions

Advice Required from Occupational Health

What is the employee's current fitness for work? Likely date of return to work? What effect will this condition have on the employee's ability to carry out his/her duties? Are there any modifications / adjustments which would alleviate the condition or aid rehabilitation? Are there any particular duties the employee cannot do? What duties can the employee perform? Is the condition likely to re-occur in the future?

Note: These pre-set questions are configurable in Form Customisation and appear on all manager forms, with the ability to add up to 5 ad‑hoc questions.

PO / Reference Number (optional)

Ad-hoc Questions (up to 5)

Triage

Triage Analysis Complete

Health Issue

MSK (Musculoskeletal)

Recommended Service

MSK Tele Management Referral (60)

Reasoning

The symptoms described align with musculoskeletal issues that can be effectively managed through teleconsultation. The 60-minute duration allows for comprehensive assessment and management planning. Previous similar cases have shown high success rates with this approach.

Appointment Booking

Recommended Service

MSK Tele Management Referral (60 minutes)

Can you book the appointment with the employee now?

Yes, book now

Select appointment time

No, book default

Book a default appointment and send them a rebooking link

Select Preferred Appointment

Dr. Sarah Mitchell

Monday, 15 Jan 2024 at 10:00 AM

Teleconsultation

Dr. James Wilson

Tuesday, 16 Jan 2024 at 2:30 PM

Teleconsultation

Dr. Emma Thompson

Wednesday, 17 Jan 2024 at 10:00 AM

Teleconsultation

Dr. Michael Brown

Thursday, 18 Jan 2024 at 11:45 AM

Teleconsultation

Dr. Lisa Anderson

Friday, 19 Jan 2024 at 3:00 PM

Teleconsultation

Confirmation Summary

Employee: -

Service: -

Appointment: -

Email confirmations will be sent to:

Employee
Referrer (manager)
Internal admin or OH team

Confirm Employee Details

Please review the employee information before proceeding.

Employee Details

Name: Sarah Johnson

Date of Birth: 15/03/1985

Job Title: Senior Software Developer, IT Department

Employee ID: EMP001234

Work Location: London Office

Length of Service: 2-5 years

Line Manager: Michael Brown

Email

sarah.johnson@company.com

Used for confirmations and notifications

Phone

+44 7700 900123

For booking updates and follow-ups

Wellbeing Questions

Reason for Referral

Homeworker Assessment

Musculoskeletal Assessment

(Please provide details of the condition and how it affects the employee)

Counselling

(Please provide details of the issues and how they affect the employee)

Has a stress risk assessment been carried out?

Yes

No

Service Required

Manager Comments

Are previous assessments available?

Purchase Order Number

Supporting Documentation

Choose Files PDF, DOC, DOCX up to 10MB each

Select Employee

Make a referral

Select Referral Type

About the Employee

Employee Details

Reason for Referral

Additional Referral Information

Referral Questions

Triage

Triage Analysis Complete

Appointment Booking

Recommended Service

Can you book the appointment with the employee now?

Select Preferred Appointment

Default Appointment Details

Rebooking Portal

Confirmation Summary

Confirm Employee Details

Employee Details

Wellbeing Questions