Disability Eligibility Assessment Please complete the following Assessment form and we will contact you within one business day to follow up. 1. CONTACT INFORMATIONName* First Last Email Address* Telephone Number* Preferred method of contact* Phone Email Preferred time of contact* Morning Afternoon Evening Other Other time of contact Are you the person with the disability?* Yes No Your age Your province of residenceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonApplicant name First Last Applicant age Applicant province of residenceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAre you currently receiving disability benefits? Yes No How did you hear about us?SelectFriendDoctorTherapistWebsitePublicityOtherOther 2. DISABILITYType of disability*Addictions including alcohol, gambling, drugs etc.Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, ADD, ADHDAnxiety Disorder, Panic AttacksAlzheimer's DiseaseAmputationAmyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)AnginaAnorexia/ Bulimia and other Eating DisordersAsthmaArthritisAuditory Processing DisorderAutism Spectrum disorder including Asperger's syndrome, Non-Verbal Learning Disorder Bi-polar syndromeBlindnessCerebral PalsyChromosomal AbnormalityChronic Fatigue DisorderChronic Pain disorderColitisCoronary Artery diseaseCrohn's DiseaseDeafnessDementiaDepressionDevelopmental DelayDissociative Identity DisorderDown's syndromeDysgraphiaEpilepsyFetal Alcohol syndromeFibromyalgiaGender Identity DisorderGlobal Developmental DelayGlut1 DeficiencyHepatitis CHuntington's DiseaseHypothyroidismHypotoniaInfant EpilepsyIrritable Bowel syndromeLearning DisabilitiesManiaMental IllnessMental retardationMicrocephalyMigrainesMultiple SclerosisObsessive Compulsive DisorderOppositional Defiant DisorderOsteoarthritisParkinson's DiseasePost-Traumatic Stress DisorderPrader-Willi syndromePsychosisQuadriplegicRetinoschisisSchizophreniaScoliosisSeizure DisorderSleep apneaSleep disorderSpeech disorderSpinal Cord InjuryStrokeTourette's Syndrome-Tic disorderTumorOtherHint: Use CTRL + CLICK to select multiple valueOther Disability Year of Diagnosis Diagnosed by Doctor* Yes No Unknown CommentsCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
