ACT Referral Form

  • Ministry Funding Referral Form

    Intake Process Information: Our intake process typically takes 1–2 weeks to complete. During this time, we assist with signing up and processing the required paperwork with the Ministry of Social Development and Poverty Reduction. Once you are successfully registered, ride requests can be processed much faster. Steps to Get Started: 1. Fill out this Referral & Inquiry Form. 2. A team member will contact you to explain how our program works and assist with completing the paperwork. 3. Once registered, you’ll be able to schedule rides.
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  • Who is making this transportation request?*

  • Client Consent Question

    If you are a support worker/family member representing a client, please ensure you have received verbal consent by the client prior to filling out this referral form on behalf of the client.
  • Verbal Consent Received by Client?*

  • Thank you for your interest in Assisted Care Transportation! 
    Unfortunately, we are unable to process your request without the Client's Verbal Consent.

    Please contact us if you have any questions.

    Phone #: 250-800-0569

    Fax #: 250-900-0559

    Email: info@actransport.org

     

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  • Client Eligibility Assessment Questions

  • Client's Needs Assessment (Please select one)*
  • Client Disability Benefits Designation (Please check all that apply)*

  • Upcoming Appointment Schedule

    For clients who are currently in treatment and or have upcoming appointments.
  • Date and Time of Next Upcoming Appointment
     - -
  • Is Treatment Ongoing?

  • Contact Information of Client's Health Support Worker or Family Member

  • Format: (000) 000-0000.
  • Relationship with Client*

  • Client Information

  • Are you (Client) Indigenous ?*
  • Client Date of Birth *
     - -
  • Client Gender*
  • Who referred you to Assisted Care Transportation?
  • Should be Empty: