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ADP Referral Form
Please fill out this intake form as the initial step for getting funded by the Assistive Devices Program (Ontario residents only). We will then reach out to you with next steps.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
ODSP Member ID (If Available)
Your answer
Place of residence
*
House
Apartment/Condo
Other:
Device Requested
*
Mobility Scooter
Manual Wheelchair
Power Wheelchair
Tilt-Chair
Other:
Do you have any other equipment previously funded by ADP?
*
No
Yes
Please tell us a bit about the reason for why you are applying for a medical device through the Assisstive Devices Program (you can include physical hardships and/or diagnoses).
*
Your answer
Please let us know if there is anything additional we should note.
Your answer
How did you hear about us?
Friend/Family/Word of mouth
Google
Advertising
Returning client
Other:
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