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.
Who is making this transportation request?*

The client (requesting rides for themselves)A representative (requesting rides on behalf of the client)

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?*

YesNo

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

Click here to be redirected back to our home page

Client Eligibility Assessment Questions
Client's Needs Assessment (Please select one)*

Currently in treatment, and needs onboarding to AC Transport for future rides.Has upcoming appointments, and needs onboarding to AC Transport for scheduled rides.No appointments yet, but will need onboarding to AC Transport for future consultations.
Client Disability Benefits Designation (Please check all that apply)*

PWD (Person With Disabilities)MSO ( Medical Services only) - 65PPMB ( Persons with Persistent Multiple Barriers)CPPD ( Canada Pension Plan Disability)IA (Income Assistance) *Rides Eligible ONLY for life threatening conditionsNot on PWD but wants to Register (Eg. Medical EI)

Upcoming Appointment Schedule

For clients who are currently in treatment and or have upcoming appointments.
Date and Time of Next Upcoming Appointment

MonthDayYear
Date
Hour MinutesAM/PM Option
Hospital/Clinic Address and Department Name
Specialist Name
Telephone
Referring Medical Practitioner
Telephone
Is Treatment Ongoing?

YesNo
How Long?
Number of times per week/month

Contact Information of Client's Health Support Worker or Family Member
Name of Support Worker/Family Member*

First NameLast Name
Phone number*
Email Address*
Fax Number of Advocate
Please enter a valid fax number.
Name of: Organization / Agency / Care Center / (n/a if not applicable)*
Relationship with Client*

FamilyCase worker ( social worker, clinician, outreach worker)Support StaffNurseMedical Office Assistant (MOA)PharmacistDoctor

Ministry Funding Referral Form