Occupational Therapy Referral Form

USC OCCUPATIONAL THERAPY FACULTY PRACTICE 2250 Alcazar Street, CSC-133 Los Angeles, CA 90089-9068 (323) 442-3340 / Fax (323) 442- 3351

OCCUPATIONAL THERAPY REFERRAL FORM Patient name: Phone: Address: Diagnosis: ICD-9: Secondary Diagnosis: ICD-9: History/Precautions:

Physician’s Name/ Title: ______Phone:______Address: ______NPI #:______Please send referral and current history to: USC Occupational Therapy Faculty Practice EVALUATION and REPORT OCCUPATIONAL THERAPY EVALUATION AND TREATMENT

Frequency/Duration: times weekly for weeks

□ Lifestyle Redesign® for the College Student (Weekly academic planning, environment assessment, time management strategies, problem solving, organizational skills, focus and concentration, increasing motivation, adaptive strategies, pain management, creating a balanced lifestyle, social skills training, interpersonal problem solving, stress management, goal setting)

□ Lifestyle Redesign® Weight Loss Program (Facilitate clients’ development and enactment of a customized routine of health promoting and meaningful activities designed to result in improved life satisfaction and weight-loss)

I certify re-certify that I have examined the patient and that services will be furnished while the patient is under my care, and that the plan is established and will be reviewed every 30 days, or more often if the patient’s condition requires. I estimate that these services will be needed for about months.

PHYSICIAN’S SIGNATURE DATE USC OCCUPATIONAL THERAPY FACULTY PRACTICE 2250 Alcazar Street, CSC-133 Los Angeles, CA 90089-9068 (323) 442-3340 / Fax (323) 442- 3351

Freeway Directions:

From 10 Eastbound Exit at Soto and turn left. Then make a left on Alcazar.

From 10 Westbound Exit at Soto and turn right. Then make a left on Alcazar.

From 5 Southbound Exit at Mission and turn left. Right on Zonal. Left on San Pablo. Right on Alcazar.

From 5 Northbound Transition to 10 Eastbound. Exit Soto and turn left. Left on Alcazar.

From 101 Southbound. Transition to 10 Eastbound. Exit at State/ Soto. Proceed across State onto onramp, and bear right to exit at Soto. Make a left on Soto, and then a right on Alcazar.

From 710 North or Southbound Transition to 10 Westbound. Exit at Soto and turn right. Make a left on Alcazar.

From Huntington Drive (Pasadena, West San Gabriel Valley) Follow Huntington westbound until it divides into Mission Road and Soto St. Bear left onto Soto and proceed to Alcazar. Turn right onto Alcazar.