Client Referral Form

Referring Party:

Full Name

Company / Firm

Mailing Address

City

State

Zip

Phone

Email

Facsimile

Laris Rehabilitation Services Requested:

Vocational EvaluationJob PlacementLabor Market SurveyMedical Case ManagementUnsure, please contact meOther

Please explain

Evaluee/Injured Worker/Claimant Information:

Full Name

Middle Initial

Mailing Address

City

State

Zip

Phone

Diagnosis

Injury Date

Claim Number

Case Type
Work CompPersonal InjuryMed MalDivorceOther

Legal Representation:

Is the Evaluee/Injured Worker/Claimant represented by another attorney or other legal representative?

YesNo

If YES, name of attorney/legal representative:

Full Name

Company/Firm

Mailing Address

City

State

Zip

Telephone

Email

Facsimile

Special Needs:

Please advise of any hearing/trial/deadline dates or special needs: