ADP Referral Form

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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.

Email *

Name *

Phone Number *

Address *

ODSP Member ID (If Available)

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? *

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). *

Please let us know if there is anything additional we should note.

How did you hear about us?

Friend/Family/Word of mouth

Google

Advertising

Returning client

Other:

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Send me a copy of my responses.

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