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WorkSafeNB Rehabilitation Centre Referral (WRC)

Physicians and nurse practitioners use this form to refer a WorkSafeNB claimant to WorkSafeNB's Rehabilitation Centre for services, or to request supplies. Page 1 gives the claimant, referral source, reason for referral or goal and admission details; page 2 lists the services to choose from, including work recovery team programs, education sessions, single-discipline services and vocational evaluations.

Who completes it

The referring physician or nurse practitioner completes the claimant, referral-source and reason or goal sections, then enters their name and the date as Completed by. For a supplies request, only the Supplies Required/Authorized box is needed.

Submitting and payment

How to submit it
Send it through MyServices secure email, by toll-free fax, by mail or in person; if you fax it, don't mail it as well.
Who pays
The form has no billing section; WorkSafeNB asks providers to bill on the reporting form designed for their profession, such as Medical Form 8-10 for physicians and nurse practitioners.

Good to know

  • Work recovery team programs include work hardening, cumulative trauma disorders, CRPS, traumatic psychological injuries, mild traumatic brain injury, opioid reduction, stalled return to work and amputee rehab.
  • Single-discipline services include work conditioning, physiotherapy, occupational therapy, psychological and social work counselling, biofeedback, TENS, nutrition counselling and gradual return to work.
  • Flag an urgent admission or re-admission, a requested admission date, whether a hotel is required, the client's language and any caution flag.
  • Vocational evaluations include work capacity evaluation, psychological assessment, ergonomic evaluation, risk factor analysis, and job site evaluation or analysis with the job title and contact.

Get the official form

Download the current version from the source each time; forms change without notice.

Referral Service Form WRC

Client adressé pour une admission au Centre de rééducation professionnelle

Official pagePDFVersion française

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

What can I refer a worker to at WorkSafeNB's Rehabilitation Centre?

The form lists work recovery team programs such as work hardening, CRPS, traumatic psychological injury, mild traumatic brain injury and opioid reduction; education sessions on pain, stress, sleep and safe work; single-discipline services; and vocational evaluations including work capacity and job site evaluations.

Can I use the WRC form to request supplies?

Yes. Tick Supplies Request instead of Referral for Service, and complete only the Supplies Required/Authorized box along with the claimant and referral-source details. The printed title is WorkSafeNB's Rehabilitation Centre Referral for Service / Supplies Request.

Is the WRC referral form available in French?

Yes. WorkSafeNB's French-language forms list links Client adressé pour une admission au Centre de rééducation professionnelle on travailsecuritairenb.ca. The English form is listed for physicians and nurse practitioners on the health care forms page.