How to Complete a Referral Form

To achieve a successful and meaningful management referral report, the first step is always the completion of a good management referral form by the employer. This is your opportunity to really get the best from the occupational health management referral process.

Once you have received our user-friendly Management Referral form (either by downloading a copy from the bottom of this page or by contacting our Admin Team on info@workplacewellness.health), please follow the advice below:

• Consent: Please ensure the consent tick-box section at the top of the form is completed as a priority.

Is the employee aware of this referral?

Has the employee had sight of the contents of this referral?

Has the employee agreed to an Occupational Health consultation?  

The answers to all these questions should be ‘yes’. If not, we will need to make contact before we can proceed further.

It is imperative that the employee has had sight of the completed referral form so they are aware of everything that will be brought up during the consultation. Do not supply additional information by email or telephone since the employee will not be aware of this type of liaison. Transparency is key, and it is imperative that the employee has had sight of everything that is being discussed in the consultation.

It is crucial that the referral includes actual evidence of the employee’s consent. Please see the instruction in the ‘Signature’ section below.

• Employee specifics: Complete Name, Date of Birth, Job Role, Contracted Hours, Place of Work and Shift Pattern. In the subsequent section, please give a brief description of the job role including any hazards encountered.
• User constraints: We need to know if the employee requires a translator, has disability requirements (e.g. would struggle with stairs) or do they have any difficulty using TEAMS software for a video consultation? Please make it clear at the outset whether an employee would have difficulty attending the clinic if it was felt that a face-to-face appointment would be most appropriate. For your information, we rarely ever recommend a telephone appointment as this is not ‘best practice’ and vital elements of the case could be missed by the clinician if the employee could not be seen visually.
• Employee details: Ensure that all the employee details are correct. It is vital that we know where they live if we feel a face-to-face appointment would be most appropriate (however, we will nearly always opt for TEAMS if this was logistically problematic for the employee to attend our Wiltshire-based clinic).
• Employer details: Please ensure the employer details are completed correctly so that we can contact you and know who the report is to be sent to.
• Type of referral: Tell us what type of referral you are making, e.g. return to work advice etc.
• Health concern: Please provide the health concern that has led you to make the referral e.g. mental health, musculoskeletal. Fill out any absence details and if any disciplinary or grievance issues impact the case.
• Referral explanation: Please give more details on the medical condition (or the symptoms if there are no diagnoses). What is the condition/suspected condition? What work concerns have led to this referral? What outcome are you expecting from the referral process (e.g. phased return advice, reasonable adjustments)? Please be as detailed as possible in this section as it will aid us in producing a meaningful report.
• Other information: Please provide any additional information you feel would be helpful for us to be aware of.
• Adjustment section: What adjustments are already in place?
• Questions to be answered: As a standard, we will always answer these questions:

What is the current health situation?

Fitness for work.

Recommendations to support the employee at work?

Review plans.

You have the opportunity to add additional questions in the box below. However, if there are more than five extra questions, an extended appointment may be required as the clinician may not have time allocated to discuss them fully.

• Signature: Please ensure your employee has sight of the completed form and then signs the bottom of the form (if they are absent from work and unable to do this, please request that they sign remotely, stating they have viewed the full referral form).

Please see below our mock-up template to give you an idea how we would expect a form to be completed by the employer.

If you require further advice on the referral process or completing the form, please do not hesitate to contact us. A successful and valuable report hinges on a well-completed form, so it’s a good idea to make sure the form is as detailed as possible from the outset.