Washington attending providers use this one-page referral to enroll an injured worker in L&I's Activity Coaching program, which uses the Progressive Goal Attainment Program (PGAP). If eligible, the worker meets weekly with an activity coach for about an hour, up to 10 sessions, in person or by phone, working to resume activities and return to work when feasible.
The attending provider completes and signs the form, confirms the eligibility criteria, and notes whether coaching was discussed with the worker and any coach preference. An L&I therapy services reviewer completes the department block.
Download the current version from the source each time; forms change without notice.
Referral for Activity Coaching Program
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.
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 and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The attending provider. A worker can ask their provider for the referral, but the provider section, including the signature, is completed by the attending provider. Therapists can suggest activity coaching to the AP through the services-to-consider section of the Physical Medicine Progress Report.
Up to 10 sessions, held weekly for about an hour, and meetings may be by phone. Coaches use the Progressive Goal Attainment Program: early stages focus on structured tasks to help the worker resume activities, and final stages on returning to the workplace when feasible.