Technology Accessibility Program – Online Referral Form "*" indicates required fields Program ChoiceProgram Choice * Required Technology Accessibility Program Client InformationClient Name * Required First Last Date of Birth: * RequiredGenderFemaleMaleOtherAddress * Required Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone * RequiredEmail Languages SpokenSmokes? * 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?Please select the topics you are interested in learning about: Tablet basics Internet Email Camera Texting/Messaging Social Media Video Calls (FaceTime, Zoom) Games Online Safety 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 * RequiredSubstitute Decision Maker? * RequiredNoYesNot ApplicableMain Phone * RequiredWork PhoneMobile PhoneEmail Referral InformationWho is making this referral? * RequiredSelfFamily MemberFriendProfessionalOtherReferral Name * Required First Last Referral Phone * RequiredReferral 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 CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
