Client Intake Form

Name

Date of Birth

What gender do you identify with?

Female

Male

Non-binary

Rather not say

Street Address

Street Address Line 2

Town/City

Postal Code

Phone

Email

How did you hear about us?

Why are other modes of transporation unsuitable right now?

What is your most urgent transporation need ?

What makes it hard to get where you need to go?

Will a referring agency subsidize transporation?

Do you have access to any other potential financial assitance to help you get where you need to go?

Do you have difficulty walking or climbing steps?

No, no difficulty

Yes, some difficulty

Yes, a lot of difficulty

Cannot do it at all

Do you use any kind of equipment, such as a wheelchair, walker, or cane to help you get around?

Do you have difficulty going outside of your home?

No, no difficulty

Yes, some difficulty

Yes, a lot of difficulty

Cannot do it at all

By yourself and not using aids, do you have any difficulty

Walking for 2-3 blocks?

Walking up ten steps without resting?

Standing or being on your feet for about two hours?

Sitting for about two hours?

Stoopoing, crouching or kneeling?

Getting in/out an elevator?

Do you have a hearing impairment?

Do you have a visual impairment?

Do you have scent sensitivities?

Do you require a smoke free car?

Do you require a scent free car?

Do you smoke?

Will you be travelling with children?

No

Yes, please answer the following seven questions

What is the name(s) of the child(ren)?

What is the DOB of child 1?

And of child 2?

And of child 3?

And of child 4?

Do the children you are travelling with require a car seat by law?

No

No, they are at least 8 years old, weigh more than 36kg (80 lb.) and are at least 145 cm (4'9") tall

If they require a car seat, can you bring one that is age appropiate?

No (please know that we cannot transport you)

Yes

If they require a car seat, can you bring one that has the Canadian Safety Mark?

Yes

No (please know that we cannot transport your child)

If they require a car seat, can you bring one that is not expired?

Yes

No (please know that we cannot transport your child)

If they require a car seat, can you install it yourself in the driver's car?

Yes

No (please know that we cannot transport your child)

Will you be travelling with a companion?

No

Yes, please let them fill out an intake form as well

If you are travelling with a service animal, please mention the name and species

Emergency contact name

Emergency contact phone

Are you willing to participate in our survey in the beginning of the New Year?

Yes

No

If there anything else you would like to disclose in order for us to serve you best (including a history of panic attacks, motion sickness, fainty)?

Register as a Client

Ride Details