REFERRAL FOR PARTICIPATION

The Next Step to Active Living is a Therapeutic Recreation programlinking adults with acquired physical disabilities to an active independent lifestyle within the community. Acceptance to the Next Step to Active LivingProgram requires physician approval.

By signing below, I agree that my health card number and the information in this form may be collected and used by the City of Mississauga to provide the Next Step to Active Living Program services to me and that this information may be shared with Community Care Access Centre (“CCAC”) for CCAC to provide its services to me. I also authorize my physician to provide the information requested below to the City of Mississauga for use in the Next Step to Active Living Program and to Community Care Access Centre for the purpose of providing CCAC services to me.

Participant Signature:______Date: ______

PARTICIPANT INFORMATION

Name: ______Male Female

Health Card #______

Address: ______

City: ______Postal Code: ______

Telephone (DAYTIME):______

Date of Birth: ____/____/____Trans Help#: ______

dd mm yy

Emergency Contact:______Relationship: ______

Daytime Telephone Number: ______

Referred By: THP–CVH THP – MISS Self Other______

Referral Name: ______Telephone: ______Fax: ______

PHYSICIAN’S SECTION (PLEASE PRINT)

Primary Diagnosis: ______Date: ______

Secondary Diagnosis: ______

Date: ______

Medical History: ______

______
______

PHYSICIAN’S CONSENT: (PLEASE PRINT)

______may participate in the Next Step to Active Living Program with the following guidelines:

Unrestricted physical activity (starts slowly and builds up gradually)

Progressive physical activity with avoidance of ______

Progressive physical activity with inclusion of ______

Current Blood Pressure: ______Date: ______

Seizure: Yes NoIf yes, date of lastseizure: ______

Allergies: Yes No If yes, please specify: ______

______

Diabetic: Yes No

Hot tub (40° Celsius): Yes No Sauna: Yes No

Doctor’s Stamp: / Doctor’s Signature:
______
Date: ______

Please complete the following sections, where applicable:

PHYSIOTHERAPY

Ambulates: ______metersIndependentlyMin. SupervisionMax. Assistance

Gait Aid: No Gait Aid Cane Walker Wheelchair Scooter

Supervision Required: ______

Contraindications: ______

______

Pool Experience: Yes No

Exercise Program: ______

______

Goals and Strategies: ______

______

OCCUPATIONAL THERAPY

Cognitive Ability: ______

______

Physical Function: ______

______

Personal Care: ______

______

Goals and Strategies: ______

______

SPEECH THERAPY

Areas of Difficulty:______

______

Goals and Strategies: ______

______

Revised November 2013