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Free Assessment
Section 1 – General  
Name of Person with Disability
Name of Supporting Family Member (if applicable)
Date of Birth
Email
Telephone
Address
Type of medical condition/s
Year symptoms began
Year diagnosed
Section 2 – Physical Impairments  
  • Is the applicant visually impaired or blind?
  • Does the applicant have a speech impairment?
  • Is the applicant hearing impaired or deaf?
  • Does the applicant have difficulty walking 100 meters (1 city block) without stopping?
  • Is the applicant unable to dress independently or have difficulty dressing?
  • Does the applicant have difficulty managing bowel or bladder functions?
  • Is the applicant unable to feed themselves independently?
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
Section 3 – Mental impairments  
  • Is the applicant unable to solve problems or make appropriate decisions?
  • Is the applicant unable to leave the house due to anxiety, fear or depression?
  • Does the applicant suffer from panic attacks or social anxiety?
  • Is the applicant easily distracted all or most of the time?
  • Has the applicant changed schools or attended special education program due to their impairment?
  • Has the applicant been hospitalized due to their impairment?
  • Has the applicant had suicidal thoughts or ever attempted suicide?
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
Section 4 - Other  
  • Has the applicant been approved for the DTC in the past?
  • Does the applicant pay taxes?
  • Does a family member support the applicant with food, clothing or shelter?
  • Has the applicant ever declared bankruptcy?
  • Does the applicant currently live in a nursing home?
  • How did you hear about us?
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  •  Yes No
  • Specify

 
 
 
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