General Services


Legal Representative (If Applicable)

Services Requested (select at least one service)

Housing/Accessibility Needs Evaluation
Hospital Discharge Planning Home Safety Assessment
Wheelchair and Mobility Assessment, including Ontario Assistive Devices Program (ADP)
Workplace Ergonomic assessment and Modifications
Other - please specify in box below

Work Hardening/Conditioning

Occupational Therapy Education/Treatment session
Progressive Goal Attainment Program (PGAP)

Referral Source