*First Name (of the person to be assessed)
*Last Name (of the person to be assessed)
*Phone number (with area code)
Alternative contact number (with area code)
Email address (optional) Address of the Person that Needs to be Assessed *House Number
Apartment/Unit # (if applicable)
*Street Name
*City/Town —Please choose an option—BarrieBellevilleBramptonBrantBrantfordBrockvilleBurlingtonCambridgeClarence-RocklandCornwallDrydenElliot LakeGreater SudburyGuelphHaldimand CountyHamiltonKawartha LakesKenoraKingstonKitchenerLondonMarkhamMississaugaNiagara FallsNorfolk CountyNorth BayOrilliaOshawaOttawaOwen SoundPembrokePeterboroughPickeringPort ColbornePrince Edward CountyQuinte WestRichmond HillSarniaSault Ste. MarieSt. CatharinesSt. ThomasStratfordTemiskaming ShoresThoroldThunder BayTimminsTorontoVaughanWaterlooWellandWindsorWoodstock
*Postal code *Is this assessment for you? (Self Referral) YesNo If No Please Select one of the following: I'm the requester of this assessment for a family member or a friendI'm a health care professional requesting this assessment for one of my clients/patientsI'm a lawyerI'm an insurer/adjustor (for insurance companies Only) Is this your first time to refer someone/or be referred to London Rehab? YesNoUnsure If you are NOT self-requester, please complete the required information below:
Requester's First Name
Requester's Last Name
Requester's Phone Number
Requester's Email Address Best Time to Contact You: In the MorningIn the AfternoonIn the EveningAnytime A designated capacity assessor will contact you shortly to verify your information, and may go through screening questions to obtain some more information for this assessment. The assessor may need to have you complete a formal form for this request as part of the legal documents that need to be submitted to the Ministry of Attorney General (The Public Guardian and Trustee PG&T Office). Thank you! * Please list your concerns and observations about the individual that needs to be assessed. If you are a self-requester (the person who needs to be assessed) then please tell us the reason(s) you think you would need this assessment (from your perspective). You can list any medical or health related issues, including cognitive (memory related) issues.
Please check this box if you are NOT the person that needs to be assessed. Please check this box if you are a self-requester (same person completing this form who needs to be assessed). By continuing, you agree to provide us with your written informed consent to share all of your personal and health information (PHI) with us for the legal mental capacity assessment purposes, and you agree to our Privacy Policy and Terms of Service. By continuing, you agree to our Privacy Policy and Terms of Service.
