Client Intake Form

Please Note: As of May 1, 2025, we are updating our fee for service. For more information about our new pricing structure, please click here, or reach out to a staff member at 905-722-4616 x 1

NEW CLIENT INTAKE

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Client Intake Form

Register as a Client

Our compassionate transportation services are provided to residents of York Region who cannot, because of their financial, physical or mental challenges, travel by conventional transit or taxi.

Please fill out the following information to register as a Routes client. After submission, a staff member will get back to you to finalize your intake.

**NOTE: We require 3 full business days' notice for ride requests. Our business days are Monday-Friday from 8:30am-4:00pm, minus statutory holidays. Ride requests made after hours or on weekends DO NOT count until the next business day when our staff has the chance to review the request.

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 transportation unsuitable right now?

What is your most urgent transportation need ?

Medical appointments

Groceries

Food Pantry/ Food Bank

Community Meals

Recreation

Personal

Family/ Friends

Education

Financial Help

Work

Other shopping

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

Senior

Victim of Abuse

Living alone

Stigmatized population

No family close by

Intergenerational care need

Isolated from transit routes

No vehicle during work hours

Accompaniment need

Mental illness or anxiety

Cultural factors

Frailty or impact of aging

Dependence on substances

Persistent treatment schedule (e.g. dialysis, chemotherapy, physiotherapy)

Domiciliary resident

Chronic Illness

Physical disability

Acute Illness

ODSP

Complex economic barriers

OW/CPP

High expense due to illness/disability

Low income

Will a referring agency subsidize transportation?

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

Private insurance

Lawyer

ODSP

Community based agency

Family or personal network

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?

Stooping, 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?

Yes

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 appropriate?

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

Is 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)?

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Routes Connecting Communities Inc.

Charitable registration number: 888551868RR0001

20849 Dalton Road, P.O. Box 160, Sutton West, ON, L0E 1R0

info@routescc.org | (905) 722-4616

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