Please complete the following information to refer a employee for a face to face assessment to be completed by an occupational rehabilitation consultant.

We will contact you to arrange the assessment once we have received the completed referral form.

Please contact Ergability at or call 03333 554 184 if you require any additional information.

Referring employer name *
Referring employer name
Consent to referral *
Has the employee consented to a referral? (N.B. This is required to proceed with the assessment)
Employee's name *
Employee's name
Goals for assessment (information required) *
Employee's current work status *
Does the employee have a current fit note? *
Does the employee regularly work night shift (working between 10pm and 4am)? *
Details of job demands *
Please check the relevant boxed below for specific demands that are required as part of the employee's job role
Please advise if your company provides any of the following health and / or wellbeing services