REFERRAL FORM FUNCTIONAL DRIVING EVALUATION MY CONTACT INFORMATION My Name and Title: My Company Name: My Tel #: My Email: DRIVER INFORMATION First Name: Last Name: Date of Birth: Preferred Pronouns: PHN: Address: (100 chars left) Telephone #: Email Address: Date of Loss (if applicable): Claim/File # Driver’s License #: License Expiry Date: Driver’s License Status: Please select one Valid Cancelled Unknown REFERRAL INFORMATION Medical Condition or Diagnosis: (250 chars left) REASON FOR REFERRAL: Functional Driving Evaluation (FDE): Driver’s ability to compensate for skill deficits (cognitive, visual, physical and behavioral) will be evaluated by occupational therapist during in-clinic and on-road testing. Please choose: Class 5 Class 7 N/L Class 1-4 Unknown Is an assessment for Vehicle Modifications needed? Yes No Anticipated vehicle modifications are: Spinner knob Left foot accelerator Hand controls Unknown N/A Does the driver presently use vehicle modification to drive (i.e. hand controls, left foot accelerator, spinner knob)? Yes No Unsure PLEASE LIST MODIFICATIONS REQUIRED Does the driver use mobility aids such as a wheelchair or power mobility? Yes No Unsure PLEASE LIST MOBILITY AIDS USED: IF DRIVER USES A WHEELCHAIR PLEASE CLARIFY IF IT IS RIGID OR COLLAPSIBLE Can the driver independently transfer into a sedan sized vehicle? Yes No Unsure Does the driver require any transfer equipment? Yes No Unsure PLEASE LIST REQUIRED TRANSFER EQUIPMENT Has funding been confirmed? Yes No Did you receive a letter from RoadSafetyBC? Yes No If yes, please This email address is being protected from spambots. You need JavaScript enabled to view it. for review. PHYSICIAN INFORMATION Family Physician / Nurse Practitioner: Physician / Nurse Practioner Address: (100 chars left) Physician Tel #: Physician Fax #: FUNDER / PAYER INFORMATION Funder Name and Title: Funder Company Name: Funder Tel#: Funder Email: Functional Driving Evaluations are conducted by registered Occupational Therapists. Evaluation protocols meet the standards set out by the Driver Medical Fitness Program RoadSafetyBC. Please contact our Service Coordinator at 604-566-8457 or email us at This email address is being protected from spambots. You need JavaScript enabled to view it. for more information about our Driver Rehabilitation Program. Submit Thank you for completing our driver rehab referral form – we will contact you soon. Please turn on javascript to submit your data. Thank you! OK
