Canadian Disability Specialists Assessment

1
What is your name?* This field is required.
First Name
Last Name
2
What is your phone number?* This field is required.
Please enter a valid phone number.
3
What is your email address?* This field is required.
example@example.com
4
What is your home address?* This field is required.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Who is the Disability Tax Credit application for?* This field is required.
Myself
My Partner
My Child or Dependant
My Older Aged Parent
Other
6
If you selected other, what is their relation to you?* This field is required.
7
What is the name of the person who will be claiming the disability tax credit on behalf of the applicant?* This field is required.Example: A parent's name as they are claiming on behalf of their dependant. If not applicable field is not required.
8
Do you have legal authority to apply for the disability tax credit on behalf of the applicant?* This field is required.
Yes
No
Unsure
9
What is the name of the applicant?* This field is required.
10
What is the date of birth of the applicant?* This field is required.
Year
Month
Day
11
What is the applicant's Social Insurance Number (SIN)?The applicant's SIN is required on the application. It can be included here or can be hand written by yourself on the paperwork afterwards if preferred. However, please note if it is forgotten on the form it will be denied by the CRA as an incomplete submission.
12
What was the sex assigned at birth for the applicant?* This field is required.
Female
Male
13
What are the applicant's preferred pronouns?This is optional
14
Does the applicant struggle in any of the following areas:* This field is required.Select all that apply
Anxiety
Autism
Borderline Personality Disorder
Bipolar
Brain Injury
Cancer
Depression
Diabetes
Disordered Eating
Dressing
Eliminating (Bladder and Bowel)
Feeding
Fibromyalgia
Hearing
Invisible Medical Condition
Learning Disability (ADHD)
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Receive life sustaining treatment for Diabetes, Kidney Failure or Cancer
Speaking
Substance Related Disorder
Trauma
Vision
Walking
Work Place Injury
Other
None of these apply
15
What Bipolar type does the applicant have?
Bipolar I
Bipolar II
Rapid Cycling
Other
16
Please describe other areas that the applicant struggles with:
17
Tell us more about the applicant's experience:* This field is required.Select all that apply
Anger
Binge eating
Challenges managing important details
Destroying property
Does not complete personal hygiene tasks
Does not make eye contact
Does not understand cause and effect
Does not understand time of day and day of week
Fixation
Fear of abandonment
Fear of rejection
Forgetting to eat and drink
Help to manage day to day tasks important to their health
Hospital visits or admission
Hyper-vigilance
Impulsive spending
Internalizing emotions
Intrusive thoughts
Irrational fears
Irrational thought processes
Lives at risk
Makes poor choices
Needs help to manage appointments important to their health
Needs help with medications
Needs reminders to complete personal care tasks
Often is unable to complete tasks
Over sleeping
Panic attacks
People pleasing
Phobias
Physical aggression
Poor insight
Poor memory
Reckless behaviours
Sadness
Sensory challenges
Socially isolates
Splitting and disassociation
Struggles to be in public places
Suicide attempts
Suicide ideation
Tantrums
Unable to complete basic tasks
Unable to concentrate and manage attention
Unable to have reciprocal conversations
Unable to identify/voice emotions
Unable to maintain employment
Unable to maintain relationships
Under sleeping
Up and down moods
Vindictive
Violence
None of these apply
18
Does the applicant require 1-1 support in any of the following areas:* This field is required.Select all that apply
Community
Ensure safety
Home
Manage social interactions
School
To attend appointments
To complete personal care tasks
To manage medications
Other
None of these apply
19
Please provide more detail how the applicant requires 1-1 support:
20
Does the applicant struggle with physical challenges that might include:* This field is required.Select all that apply
Difficulty completing tasks that require movement
Difficulty dressing
Difficulty hearing
Difficulty talking
Takes longer to walk
Unable to put on shoes
Unable to sit for extended periods of time
Use a brief for incontinence
Use of equipment (such as a cane or bed pole)
Other
None of these apply
21
Please describe other physical challenges that might impact the applicant:
22
Does the applicant have a doctor, nurse practitioner, psychiatrist, or psychologist available to sign the documents once completed?* This field is required.
Yes
No
Unsure
23
Please provide the full name and contact information of the doctor or provider that will be reviewing the Disability Tax Credit application:* This field is required.
24
How many years has the applicant been under the care of their main healthcare provider?(The doctor or provider you listed previously)
25
Does the applicant take medications?* This field is required.
Yes
No
Other
26
Are medications helpful for the applicant?* This field is required.
Yes
No
Still trying to figure it out
I have reactions to medications
27
Please provide us with more insight into the applicant's medication history:
28
Does the applicant require reminders for taking medications?* This field is required.
Yes
No
Neither of these apply
29
What types of reminders are needed?* This field is required.Select all that apply
Alarm or notification
A person who helps
Forget to take medications
Other
30
What other types of reminders are needed?
31
Does the applicant have a diagnosis?* This field is required.It is NOT required to have a diagnosis to be approved!
Yes
No
In Progress
Unsure
32
Please provide us with the applicant's diagnosis/diagnoses:* This field is required.
33
Is there an ongoing assessment of the applicant's medical conditions?* This field is required.
Yes
No
34
Tell us in your words about the applicant's medical conditions or day to day challenges:* This field is required.
35
How else does the applicant struggle daily?
36
How has the applicant addressed their medical diagnosis/condition through remedial measures?
Huge
Large
Normal
Small
Ok
Ok
37
Is there any other information or insight that you would like to share?
38
The services we provide:* This field is required.We work with you to complete a snapshot of the challenges you and your loved one experience to advocate for you to get the disability tax credit in place. We prepare the entire package for your primary care provider, which includes a personalized letter introducing the disability tax credit, and why we believe you are eligible. A flat rate of $400 that is due immediately for us to prepare and complete your package. There are no refunds, should your application not be approved, however we will not take your case unless we believe an approval is expected. We assist you with the entire process, including appeal if necessary. It can take up to 40-70 days to complete your package, as we put great detail into your approval. We can offer an expedited application for an additional fee of $200 if you need your application completed sooner. We cannot guarantee approvals, however we will support you through the entire process, which includes: preparing the disability tax credit, supporting you to submit your documents to CRA, questionnaires if additional information is requested, and receiving your maximum refund, based on your approval.
I Understand.
39
Please note that once you engage our services, no refunds will be provided* This field is required.We are dedicated to guiding you through the application process, with a primary focus on ensuring your success. The most critical factor in this journey is securing the endorsement of a qualified healthcare professional, be it a physician, psychologist, psychiatrist, nurse practitioner, or paediatrician. If you're uncertain about whether they will agree to sign your application, we strongly encourage you to initiate a conversation with them before considering our services. Our commitment to excellence ensures that your application is meticulously crafted before presenting it for your review. This thorough approach ensures that your application is not only well-prepared but also aligned with the highest standards of quality.We understand that it would be less than ideal to approach your healthcare provider with an application that they may hesitate to endorse.That's why we go the extra mile to prepare you for success. With our support, you can confidently present your application, knowing that it's expertly crafted to maximize your chances of approval. We look forward to partnering with you on this important journey and assisting you in achieving your desired outcome.
I Understand.
40
Thank you for your submission of the questionnaire for consideration of eligibility for the Disability Tax Credit* This field is required.We would like to inform you that due to the substantial volume of applications received, our review process typically requires 5-7 days for completion. We would like to emphasize the gravity we attribute to crafting your application. We understand the significance of this endeavour, particularly considering the challenges you may have faced thus far. The prospect of applying for the Disability Tax Credit can be both exciting and daunting. Rest assured that your application holds a high level of importance to us, and we are committed to dedicating the necessary time and expertise to effectively articulate your unique story and qualifications within the application. We appreciate your patience during this process, and please be assured that we are diligently working to ensure that your application is meticulously prepared and presented. Should you have any further inquiries or require assistance with any aspect of your application or other related matters, please do not hesitate to reach out to us.
I Understand.
Should be Empty: