Canadian Disability Specialists Assessment

If you are applying for more than one individual, kindly submit a single application for each person
What is your name?*

First NameLast Name
What is your phone number?*
Please enter a valid phone number.Format: (000) 000-0000.
What is your email address?*
example@example.com
What is your home address?*

Street Address

Street Address Line 2

CityProvince

Postal Code
MyselfMy PartnerMy Child or DependantMy Older Aged ParentOther
If you selected other, what is their relation to you?*
What is the name of the person who will be claiming the disability tax credit on behalf of the applicant?*
YesNoUnsure
What is the name of the applicant?*
What is the date of birth of the applicant?*

YearMonthDay
FemaleMale
What are the applicant's preferred pronouns?
AnxietyAutismBorderline Personality DisorderBi Polar 1Bi Polar 2Brain InjuryCancerDepressionDiabetesDisordered EatingDressingEliminating (Bladder and Bowel)FeedingFibromyalgiaHearingInvisible Medical ConditionLearning Disability (ADHD)Obsessive Compulsive DisorderOppositional Defiant DisorderReceive life sustaining treatment for Diabetes, Kidney Failure or CancerSpeakingSubstance Related DisorderTraumaVisionWalkingWork Place InjuryOtherNone of these apply
Please describe other areas that the applicant struggles with:
AngerBinge eatingChallenges managing important detailsDestroying propertyDoes not complete personal hygiene tasksDoes not make eye contactDoes not understand cause and effectDoes not understand time of day and day of weekFixationForgetting to eat and drinkHelp to manage day to day tasks important to their healthHospital visits or admissionImpulsive spendingIntrusive thoughtsIrrational fearsIrrational thought processesLives at riskMakes poor choicesNeeds help to manage appointments important to their healthNeeds help with medicationsNeeds reminders to complete personal care tasksOften is unable to complete tasksOver sleepingPanic attacksPhobiasPhysical aggressionPoor insightPoor memoryReckless behavioursSadnessSensory challengesSocially isolatesSplitting and disassociationStruggles to be in public placesSuicide attemptsSuicide ideationTantrumsUnable to complete basic tasksUnable to concentrate and manage attentionUnable to have reciprocal conversationsUnable to maintain employmentUnable to maintain relationshipsUnder sleepingUp and down moodsVindictiveViolenceNone of these apply
CommunityEnsure safetyHomeManage social interactionsSchoolTo attend appointmentsTo complete personal care tasksTo manage medicationsOtherNone of these apply
Please provide more detail how the applicant requires 1-1 support:
Difficulty completing tasks that require movementDifficulty dressingDifficulty hearingDifficulty talkingTakes longer to walkUnable to put on shoesUnable to sit for extended periods of timeUse a brief for incontinenceUse of equipment (such as a cane or bed pole)OtherNone of these apply
Please describe other physical challenges that might impact the applicant:
YesNoUnsure
Please provide the full name and contact information of the doctor or provider that will be reviewing the Disability Tax Credit application:*
How many years has the applicant been under the care of their main healthcare provider?
YesNoOther
YesNoStill trying to figure it outI have reactions to medications
Please provide us with more insight into the applicant's medication history:
YesNoNeither of these apply
Alarm or notificationA person who helpsForget to take medicationsOther
What other types of reminders are needed?
YesNoIn ProgressUnsure
Please provide us with the applicant's diagnosis/diagnoses:*
YesNo
Tell us in your words about the applicant's medical conditions or day to day challenges:*
How else does the applicant struggle daily?
Is there any other information or insight that you would like to share?
I Understand.
I Understand.
I Understand.
Should be Empty: