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Lawlor RSW Referral Form
Please complete this form to make a referral for RSW services, Recreational Therapy or Aqua Therapy
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CLIENT INFORMATION
Client First Name or Initial
Your answer
Client Last Name or Initial
Your answer
Clients General Location/Municipality
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Approximate number of sessions per week
Your answer
Approximate hours per session
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Type of referral
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Choose
Rehabilitation Support Worker (RSW)
Recreational Therapy Program
Aqua Therapy Program
Funding Source
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Accident Benefits
WSIB
Private
Other
Additional Information regarding your service request
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