Rehabilitation Services Referral Form

Physical Therapy Services

Evaluation & Treatment

Therapeutic Exercises

  • ROM
  • Flexibility
  • Strengthening
  • Gross motor coordination

Transfer Assessment & Training

Ambulation & Safe Home Mobility

Facilitation Techniques for Muscle Re-Education

Joint Mobilization

Myofacial Release

Gait Assessment & Training

Pain Assessment & Management

Balance Assessment & Treatment

  • Tinetti
  • Berg
  • Functional reach
  • Timed get up and go
  • Dynamic gait index
  • Timed sit to stand

OTAGO Exercise Programs

Vestibular Rehabilitation

Postural Assessment & Training

  • Back care
  • Patient instruction
  • Body mechanics

Incontinence Therapeutic Exercises

Edema Management

Scar Healing Techniques

  • Soft tissue mobilization

Physical Modalities

  • Heat and cold
  • Ultrasound
  • E-Stim
  • TENS

Orthopedic Pathways for Total Hip/Knee Replacements

Therapeutic Massage

Wound Care

Speech Therapy Services*

Speech & Language Assessment & Treatment

Swallowing Assessment & Treatment

Cognitive Assessment & Treatment

Vocalization Training

Articulation Training

Dysarthria & Apraxia Treatment

Aphasia Treatment

Alternative & Augmentative Communication Devices

  • Communication boards and books
  • Computer communication systems
  • Switch communication devices

Use of Artificial Larynx or Vocal Prosthesis

Patient & Caregiver Instruction

*Speech Therapy treats patients of all ages for both acute and chronic conditions including, but not limited to: Parkinson’s Disease, cancer, Multiple Sclerosis, ALS, Myasthenia Gravis, stroke, traumatic brain injury, surgical conditions, developmental problems.

Occupational Therapy Services

Evaluation & Treatment

Upper Extremity Therapeutic Exercise

  • Range of motion
  • Strengthening
  • Joint mobilization
  • Coordination exercises and activities

Facilitation Techniques for Muscle Re-Education

Edema Management Techniques

  • Massage
  • Positioning
  • Wrapping
  • Patient education

Pain Assessment & Teaching

  • Positioning
  • Relaxation
  • ROM
  • Pacing

Sensory Assessment & Treatment

  • Visual screening
  • Upper extremity sensation assessment
  • Desensitization teaching
  • Patient education

Low Vision Assessment & Patient Education in Adaptations/Resources

Perceptual Motor Assessment & Teaching

Cognitive Assessment & Teaching of Cognitive Strategies for Patient/Caregiver

Activity Tolerance Teaching & Training

Activities of Daily Living Assessment & Training




Adaptive Equipment Recommendation & Instruction

Home Safety Assessment & Recommendation for Environmental Adaptations

Incontinence Assessment & Education

  • Timed voiding
  • Pelvic floor strengthening
  • Skin care

Work Simplification & Energy Conservation Techniques Training

Breathing Instruction & Implementation into Activities

Joint Protection/Conservation Teaching

Wheelchair Positioning

Lymphedema Assessment & Treatment

Therapeutic massage

  • ROM
  • Wrapping
  • Measuring
  • Skin care education
  • Patient/caregiver instruction

Post Mastectomy Assessment & Instruction

Other Patient Specific Reference Information

Weight Bearing Status

  • Full weight bearing
  • Partial weight bearing
  • Toe touch weight bearing

Duration of weight bearing restriction:


  • Positional
  • Active infections present
  • Medical contraindications
  • Functional limitations
  • Surgical complications
  • Restrictions
  • Specific exercise restrictions

Cognitive Issues

Social/Family/Caregiver Issues

For more information or to make a referral, please call 800-924-2273.