221 Woodlawn Rd West, Suite B3
Guelph ON. Canada
N1H 8P4
phone 1-519-265-3145
fax 1-519-265-4736
info@dtresults.ca
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F.A.Q
Questionnaire
To get started please completely fill out the following assessment questionnaire.
All information collected will always remain confidential.
Claimant Information (Person with the Disability)
Full Name
Birthdate
Address
Primary Phone
Secondary Phone
Email
Confirm Email
Preferred Contact Time
Anytime
Morning
Afternoon
Evening
Preferred Contact Method
Phone
Email
How did you hear about us?
Current marital status
Single
Married
Common Law
Separated
Divorced
Widowed
Net Income
Source of Income
Employed - Full Time
Employed - Part Time
Unemployed
WSIB
CPP Disability
Ontario Works
ODSP
Retired
Have you claimed bankruptcy?
No
Yes
If you claimed bankruptcy, what year?
Prior to 2000
What year were you denied?
Information about the person claiming the disability amount
If different than Claimant
Full Name
Relationship to claimant
Spouse
Parent
Son
Daughter
Brother
Sister
Grandparent
Aunt
Uncle
Other
Phone #
Email
Disability Description
Please select all that apply
ADHD
Agoraphobia
Alzheimer's Disease
Amputation
ALS
Angina
Anorexia
Anorexia Nervosa
Anxiety
Arthritis
Asperger's Syndrome
Asthma
Ataxia
Attention Deficit
Autism
Auto-Immune Disorder
Bi-Polar Disorder
Bladder Disorder
Blindness
Borderline Personality Disorder
Bowel Disorder
Brain Injury
Bulimia
Celia Disease
Cerebral Palsy
Chemical Sensitivities
Chronic Inflammatory
Chronic Fatigue Syndrome
Chronic Pain Disorder
Colitis
Conduct Disorder
COPD
Coronary Artery Disease
Crohn's Disease
Cystic Fibrosis
Dementia
Depression
Developmentally Delayed
Diabetes
Difficulty Dressing
Difficulty Hearing
Difficulty Managing Bowel/Bladder
Difficulty Walking
Difficulty Feeding Oneself
Diverticulitis
Down's Syndrome
Dyslexia
Emphysema
Epilepsy
Fetal Alcohol Syndrome
Fibromyalgia
Generalized Anxiety Disorder
Glaucoma
Hearing Loss
Heart Attack
Heart Defect
Hepatitis
Herniated Discs
HIV
Huntington's Disease
Global Developmental Delay
Hypermobility Syndrome
Irritable Bowel Syndrome
Learning Disability
Lupus
Mental Illness
Multiple Personality Disorder
Multiple Sclerosis
Nerve Damage
Obsessive Compulsive Disorder
Osteoarthritis
Panic Disorder
Paralysis
Paraplegic
Parkinson's Disease
Post Traumatic Stress Disorder
Psychotic Episodes
Quadriplegic
Schizophrenia
Scoliosis
Sleeping Disorder
Social Anxiety Disorder
Speech Disorder
Stroke
If the disability is not listed above please enter it here.
Do you receive life-sustaining therapy? (Insulin pump, dialysis, etc.)
No
Yes
List any therapies or medications used frequently
Additional information you feel should be added
All the information I have provided in this questionnaire is accurate and truthful.
I Agree
Disability Tax Results has permission to contact me and follow up on the submitted questionnaire.
I Agree