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Inpatient Rehab/CCC

These forms are periodically modified. To make sure you are using the most current version of the form you require, please download it from this webpage.


All referrals must include Part 1 and Part 2 of the form below.

The form is for all referrals to inpatient rehabilitation (high tolerance and low tolerance/slowstream) and CCC, except:

  • Elective Total Joint Replacements (continue to use the MSK Preadmission Referral Form)
  • Uncomplicated Elective Cardiac Bypass/Valve Surgery at St. John's Rehab Hospital (continue to use existing process/forms at St. John's Rehab Hospital)
  • Palliative Care (continue to use existing process/forms)
  • E-Stroke (For those organizations that do not have access to the E-Stroke Rehab Referral System, please download the PDF version of the E-Stroke Rehab Referral Form)
  • Geriatric Psychiatry Program at Toronto Rehab (continue to use existing process/forms at Toronto Rehab).
  • Dialysis Service at Toronto Rehab (use the Dialysis Application Form, in addition to the Inpatient Rehab/CCC Referral Form, below) 
  • Organizations in the Toronto Central LHIN must use the LHIN's electronic Resource Matching and Referral (RM&R) system. (The referral information required in the electronic referrals is based on the information in the Network's forms.)

Inpatient Rehab/CCC Referral Form

Part 1: Inpatient Rehab/CCC Referral Form (complete for all referrals)
 

Printable-Only Form (PDF)

(must be printed, completed on paper, then faxed)

Fillable Online Form (Word)

(may be completed online, then printed and faxed)

  Inpatient Rehab/CCC Referral Form - PDF*

Inpatient Rehab/CCC Referral Form - Word*
(one document)

OR

Inpatient Rehab/CCC Referral Form - Word
(separate document for each section - all sections must be completed)

* Note: The Consent Form to Disclose Personal Health Information is available (as a separate PDF document) in the following languages: Chinese - Simplified; Chinese - Traditional; English; Greek; Hindi; Italian; Korean; Polish; Portuguese; Punjabi; Spanish; Tagalog; Tamil; Ukrainian; Vietnamese.
Part 2: Population-Specific Functional Section (complete relevant section)
 

Printable-Only Form (PDF)

(must be printed, completed on paper, then faxed)

Fillable Online Form (Word)

(may be completed online, then printed and faxed)

ABI or Neuro ABI or Neuro - PDF ABI or Neuro - Word
Amputee Amputee - PDF Amputee - Word
Burns Burns - PDF Burns - Word
Cardiac Cardiac - PDF Cardiac - Word
General/Medical General/Medical - PDF General/Medical - Word
Geriatric Geriatric - PDF Geriatric - Word
MSK MSK - PDF MSK - Word
Oncology Oncology - PDF Oncology - Word
Respiratory/
Chronic Ventilation
Respiratory - PDF Respiratory - Word
Spinal Cord Spinal Cord - PDF Spinal Cord - Word
Transplant Transplant - PDF Transplant - Word
Trauma Trauma - PDF Trauma - Word
Complex Continuing Care (CCC) CCC - PDF CCC - Word
Part 3: Discharge/Transfer Checklist (information to be sent with the patient to the post-acute destination on discharge)
  Discharge/Transfer Checklist  


Questions? Check our Frequently Asked Questions (FAQ) / Information Sheet.

Readmission? The Rehab/CCC Readmission Tree clarifies the information and processes required when patients are readmitted to rehab or CCC following a transfer to acute care. It takes into consideration medical stability, changes to functional status and what information should be sent to the rehab/CCC program.