Caredove

Sign In
English
- English
- Français

Request to Become a Referrer

Name:*

Email:*

Organization:*

Job Title:*

Work Phone:*

Message*

Cancel

Service Information
Form
Finish

Service Information

Service:

Self-Managed Attendant Services
Organization: Independent Living Centre of Waterloo Region
Description:

Direct Funding is a self-directed attendant service that allows you to be in charge of hiring and maintaining your own staff. As the employer, you are responsible for scheduling your attendants to meet your specific daily needs. You will receive monthly funds to pay your attendants, and live wherever you like in the province of Ontario.

Note:The Direct Funding program is not restricted to Waterloo Region

Eligibility:*

Are these eligibility requirements met?

Minimum Age: 16 yrs

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Registrant Information

Registrant Name:

First name*

This field is required

Family/Last Name*

This field is required

Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Phone:

Primary Phone*

This field is required

Secondary Phone

This field is required

Address:

Unit/Suite #

This field is required

Street # & Street Name

This field is required

City*

This field is required

Province/State

This field is required

Postal/Zip Code*

This field is required

Select location on a map

Gender:

Male

Female

Other

This field is required

Date of Birth:*

Day

Month

Year

Age: ( corrected)

This field is required

Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Language:

What is the preferred Language?

This field is required

Is an interpreter required?

Yes

This field is required

Conduct Appointment With:

Registrant

Alternate Contact

Referrer

This field is required

Alternate Contact

Relationship to Registrant:

Spouse

Son/Daughter

Sibling

Parent

Other

This field is required

Alternate Contact Name:

First name

This field is required

Family/Last Name

This field is required

Alternate Contact Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Alternate Contact Info:

Same contact information as Registrant

Primary Phone

This field is required

Health Information

Reason for Referral:

e.g., New Diagnosis, Recent hospital admission, Caregiver burnout, etc..

This field is required

Additional Information

Messages:

Documentation:

Send additional documentation online through Caredove, or separately via other methods (e.g., fax)

Add files

Are you sending any additional documentation separately by a method other than online through Caredove (e.g, via fax)?

Yes

Consent

By clicking "Finish", you agree to send this personal information to Independent Living Centre of Waterloo Region online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

Send confirmation, change & reminder messages to < name> < email>

Yes

Send confirmation, change & reminder messages to < name> < email>

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to Independent Living Centre of Waterloo Region, but you have some steps left:

Save Confirmation
Print a handout to give to the registrant.

A confirmation message will be sent to - -

Summary

Reference #: -

Registrant:
Organization:

Independent Living Centre of Waterloo Region

Service:

Self-Managed Attendant Services

Inquiry Phone:

1 (519) 571-6788

Tip: Referrals can be viewed by navigating to referrals in the top menu

Cancel

Appointment Service area map

Red area: Service area for this appointment

Grey area: Service delivery area

Home Address

Trip Map

Driving Distance: 0km

Select Form Name

Name:*

This field is required

Add Form Name

Name:*

This field is required

Select Location on a Map

You need Javascript enabled to use Caredove. Please visit diagnostics page for more information. #noscript-warning { font-family: sans-serif; position: fixed; top: 0; left: 0; width: 100%; z-index: 101; text-align: center; font-weight: bold; font-size: 120%; color: #FFF; background-color: #AE0000; padding: 5px 0 5px 0; }