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Disability Benefits Assistance Referral Form
cid
EVRR ID
Section One: Information of the person being referred
Person's Health Card Number
First Name
Last Name
Person's Date Of Birth
Gender
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Male
Female
Non-conforming or non-binary
Personally or culturally identified Gender
Not Applicable
Declines to Answer
Person's Telephone Number (day time or cell)
Email
Street
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territories
Postal Code
Country
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Canada
Person's preferred language
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English
French
Abkhaz
Adyghe
Afrikaans
Akan
Albanian
American Sign Language
Amharic
Ancient Greek
Arabic
Aragonese
Aramaic
Armenian
Aymara
Balinese
Basque
Betawi
Bosnian
Breton
Bulgarian
Cantonese
Catalan
Cherokee
Chickasaw
Chinese
Coptic
Cornish
Corsican
Crimean Tatar
Croatian
Czech
Danish
Dawro
Dutch
Esperanto
Estonian
Ewe
Fiji Hindi
Filipino
Finnish
Galician
Georgian
German
Greek Modern
Greenlandic
Haitian Creole
Hawaiian
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Interlingua
Inuktitut
Irish
Italian
Japanese
Javanese
Kabardian
Kalasha
Kannada
Kashubian
Khmer
Kinyarwanda
Korean
Kurdish/Kurdî
Ladin
Latgalian
Latin
Lingala
Livonian
Lojban
Low German
Lower Sorbian
Macedonian
Malay
Malayalam
Mandarin
Manx
Maori
Mauritian Creole
Middle Low German
Min Nan
Mongolian
Norwegian
Oriya
Pangasinan
Papiamentu
Pashto
Persian
Pitjantjatjara
Polish
Portuguese
Proto-Slavic
Quenya
Rapa Nui
Romanian
Russian
Sanskrit
Scots
Scottish Gaelic
Serbian
Serbo-Croatian
Sinhalese
Slovak
Slovene
Spanish
Swahili
Swedish
Tagalog
Tajik
Tamil
Tarantino
Telugu
Thai
Tok Pisin
Turkish
Twi
Ukrainian
Upper Sorbian
Urdu
Uzbek
Venetian
Vietnamese
Vilamovian
Volapük
Võro
Welsh
Xhosa
Yiddish
Zazaki
If Other language, please specify
Section Two: Supplemental personal information
VLRC office closest to the patient
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AB - Calgary
AB - Edmonton
AB - Grand Prairie
AB - Lethbridge
AB - Medicine Hat
AB - Red Deer
BC - Abbotsford
BC - Kamloops
BC - Kelowna
BC - Kamloops
BC - Prince George
BC - Vancouver
BC - Victoria
MB - Brandon
MB - Winnipeg
NB - Bathurst
NB - Fredericton
NB - Moncton
NB - Saint John
NL - Corner Brook
NL - Grand Falls-Windsor
NL - Labrador
NL - St. John's
NS - Halifax
NS - Sydney
NT - Yellowknife
ON - Barrie
ON - Belleville
ON - Brantford
ON - Cornwall
ON - Hamilton
ON - Kingston
ON - London
ON - Mississauga
ON - Newmarket
ON - North Bay
ON - Oshawa
ON - Ottawa
ON - Owen Sound
ON - Peterborough
ON - Sault Ste. Marie
ON - St. Catharines
ON - Sudbury
ON - Timmins
ON - Thunder Bay
ON - Toronto
ON - Waterloo
ON - Windsor
PE - Charlottetown
SK - Regina
SK - Saskatoon
Do you (the person being referred) identify as an Indigenous person, such as First Nation, Inuk (Inuit), or Métis?
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Yes
No
If yes, please select from the following.
If number is not known please type “Number not known” in the appropriate text box:
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Inuit-Government of Nunavut Health Plan Number
Inuk/Inuit-NIHB (N Number)
Inuk/Inuit-North West Territories Health Plan Number
First Nations-Indian Act Registration number
First Nations-NIHB ID (B Number)
Métis-Indian Act Registration number
Métis Sponsorship-Band#+Family#
This is a multi select - Use Control + Select to choose multiple options
Inuit-Government of Nunavut Health Plan Number
Inuk/Inuit-NIHB (N Number)
Inuk/Inuit-North West Territories Health Plan Number
First Nations-Indian Act Registration number
First Nations-NIHB ID (B Number)
Métis-Indian Act Registration number
Métis Sponsorship-Band#+Family#
Are you (or the person being referred) a current, former or retired member of the Canadian Armed Forces or the Royal Canadian Mounted Police (RCMP)?
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Yes
No
If yes, can you provide a K-number?
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Yes
No
If yes, please provide K-number?
Are you currently or have previously received services from Vision Loss Rehabilitation Canada?
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Yes
No
As described in more detail in the next section this form is specifically to access assistance for Federal, Provincial and Territorial programs for people with disabilities, however if you do have vision loss, are you interested in VLRC’s other services specific to people with vision loss?
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I have Vision Loss but I am only interested in accessing disability navigation services as described in the next section
I do not have vision Loss and am seeking to access disability navigation services as described in the next section
I have vision loss and am interested in accessing both disability benefits navigation services and learning about other services VLRC provides for people with vision loss
Due to your vision loss, have you (the person being referred) fallen within the last 3 months?
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Yes
No
Due to your vision loss, have you (the person being referred) burned yourself?
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Yes
No
Due to your vision loss, are you (the person being referred) at risk of losing your job?
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Yes
No
Due to your vision loss, are you (the person being referred) at risk of academic failure?
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Yes
No
Due to your vision loss, have you (the person being referred) taken the wrong medication?
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Yes
No
Are there any disability related accommodations we can provide? If yes, please include them below.
Section Three: Reason(s) for referral
Are you looking for information about the Disability Tax Credit (DTC), the Canada Disability Benefit (CDB) or other federal, provincial or territorial benefits?
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Yes
No
Would you like assistance in applying for a tax benefit or credit?
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Yes
No
Are you seeking assistance with an appeal?
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Yes
No
Is there anything else you would like to share with us?
Section Four: Consent
If you are referring yourself, do you consent to releasing your information to VLRC?
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Yes
No
If you are referring someone, are they aware of this referral and have they provided their consent to release their information to VLRC?
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Yes
No
Section Five: Referring agency information
Referral completed by
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Agency/Worker
Self-Referral
Family Referral
Name of person making referral
Organization/Relationship
Relationship
Phone number
Contact Information