Referral Form Please fill in and submit the form below. For help filling in this form please visit the WorkCover WA website. Alternatively, you can print out the form and fax or mail it to one of our offices. Workplace Rehabilitation Provider Details Worker's Name Address Address Line 2 City State Post Code Workers Email* Home Number Mobile Number Insurer Claim Number Date of injury Referral Specific Service Functional CapacityVocationalErgonomic Job DemandsWorkplaceAids & Appliances Rehabilitation Program Status of Worker Working / Full CapacityWorking / Partial Capacity Not Working / Full CapacityNot Working / Partial CapacityNot Working / No Capacity Employer Details Company Contact Name Address Phone Email Medical Practitioner Practice Name Address Phone Email Source of Referral Medical Practitioner Employer Insurer Legal Representative/Worker Referrer Name Date Additional Information / Comments / Instructions If you need upload any documents, please use the section below. Please note attachment size limit is 10MB.