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Referral Form
Comany
Insurer/Agency/Company
Branch/Division
Referrer
Case Manager First Name
Case Manager Last Name
Phone
Email
Team Name
CMS Preferred Consultant
None
Amy Hampel
Richard Tuxford
Clair Vann
Jeana Peden
Jo Kwok
Kali Antoniadis
Kate Davie
Kate Fleay
Katie Greene
Katie Kirkland
Linda Jeffrey
Marinda Wilson
Liz Bird
Richard Bradley
Tracey Fleming
Julie Wells
Brad Hartley
Paul Monson
Claimant
Claimant First Name
Claimant Last Name
Street Address
Suburb
State
NSW
QLD
SA
TAS
VIC
WA
ACT
NT
Post Code
Email
Phone Number
Legal Involvement
Unsure
Yes
No
Please Select
Date of Birth
Day
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Employment
Pre-Injury Employer
Pre-Injury Role
Employment Status
Employed
Unemployed
Employer Location
Pre-Injury Average Weekly Earnings
Pre-Injury Hours
Employment Start Date
Day
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Case Details
Case Number
Service Type
Worker's Compensation
Compulsory Third Party
Non Gratis
Income Protection
Life Insurance
Personal Injury
Retail
Outplacement
Career Transition
Career Services
Workshops
HR Consulting
Recruitment Services
Service Offering
Flourish
Optimise
Pathfinder
Thrive
Encore
Inspire
Empower
Other
N/A
Type of Service
Select Job Goal
SES (Same Employer - Same Job)
SEN (Same Employer - New Job)
NES (New Employer - Same Job)
NEN (New Employer - New Job)
Workplace Facilitated Discussion
SJSS (Specialised Job Seeking Services)
Other
Type of Referral
Job Seeking
Work Preparation
Single Services
Assessment
Work Status Code
01 : Working - Same Employer - Full Capacity
02 : Working - Same Employer - Current Work Capacity
03 : Working - Different Employer - Full Capacity
04 : Working - Different Employer - Current Work Capacity
06 : Not Working - Has no Current Capacity
08 : Not Working - Has Current Capacity
09 : Not Working - Not Entitled to Weekly Benefits
10 : Not Working - Retired
Cost Code
OR01
OR02
OR03
OR04
OR20
OR21
OR30
N/A
Pilot
Pilot
No
Pilot
Yes
Pilot Name
Injury Details
Claim Type
Select Type Of Claim
Physical
Psychological
Physical/Secondary Psychological
N/A
Nature of Injury
Medical Restrictions
Current Capacity (Hours)
Injury Note
Injury Date
Day
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Rehabilitation
Provider
Consultant First Name
Consultant Last Name
Email
Phone Number
Qualifications
Document
Authority to Exchange Information
Authority to Exchange Information
No
Authority to Exchange Information
Yes
Referral Note
Attachments
Upload Files
