Technology Accessibility Program Online Referral Form Program ChoiceProgram Choice * Required Technology Accessibility Program Client InformationClient Name * Required First Last Date of Birth: * Required GenderFemaleMaleOtherAddress * Required Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone * Required Email Languages Spoken Smokes? * RequiredNoYesPets? * RequiredNoYesIf yes, type of pet: Do you have a device (tablet, phone etc)? If yes, what device do you have? Do you have access to the internet? Medical InformationWhat health concerns should we be aware of? Mobility Incontinence Dementia Hearing Speech Vision None Other health concerns:Emergency ContactEmergency Contact Name * Required First Last Relationship to Client * Required Substitute Decision Maker? * RequiredNoYesNot ApplicableMain Phone * Required Work Phone Mobile PhoneEmail Referral InformationWho is making this referral? * RequiredSelfFamily MemberFriendProfessionalOtherReferral Name * Required First Last Referral Phone * Required Referral Email * Required Referral Organization (if applicable) Referral Position (if applicable) Reason for Referral * RequiredApprovalsClient has approved this referral?YesNoSubstitute Decision Maker (SDM) has approved this referral?Not ApplicableYesNoPermission to Submit * RequiredAcclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you. I agree CAPTCHANameThis field is for validation purposes and should be left unchanged.
