Let Us Help

Client Referral Form

New to reachAbility?

If you would like to explore our offering of free programs or schedule a tour of our operations, please fill out our new intake form below.

All information submitted in this form is confidential.

Client Information

Client Preferences

What is your client's preferred method of contact?

Does the client choose to identify as having a disability? *

(e.g. service dog, frequent breaks, enlarged print, etc)

Income Assistance

Is the client on income assistance? *

Case Worker Information

Our commitment is to ensure that case managers are informed of any programs clients choose to attend. Please call (902) 429-5878 for additional information.

Services

(Highlight or control+click as many as you wish)

Does the client have a criminal record? *
Does the client currently receive counselling or other mental health services? *
Is the client medically cleared to work? *

Have you ever been put off work by a doctor due to medical reasons?

Programming

(Highlight or control+click as many as you wish)

Education