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Full Name
I am:
A person with a disability
A caregiver of a person with a disability
A healthcare professional
A healthcare student
Other
Email Address
Telephone Number
Preferred method of contact
Email
Phone call
Text
Preferred time of contact
Morning (9am-noon)
Afternoon (noon to 5pm)
Evening (after 5pm)
Reason for Referral
I require a walker
I require a manual wheelchair
I require a power wheelchair
I require a scooter
I require a mobility aid but I don't know which one
I require a different piece of equipment
I am looking for assistive aids to help me eat, shower, dress, etc.
I am looking for a communication aid
I am looking for a Home Safety/Falls Prevention Assessment
I'd like to book an EDUCATION session
I'd like to receive more information on an educational topic
I don't know what I need
Other
Are you a recipient of the Ontario Disability Support Program (ODSP)?
Yes
No
I don't know
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