If you would like to explore how reachAbility can help you, or if you are a caseworker and would like to make a referral, please complete the form below. This information is required to ensure an efficient intake process. All information collected will remain confidential. 

Inquiries Email:

Please note: Clients will be contacted by reachAbility within 2 business days of receiving the referral.

If you would like to download a copy to fill it out manually and send it to us by fax or e-mail, please down load the form through the button below:


digital Client intake/referral form

Client Information
Client's Name *
Client's Name
Date Of Birth *
Date Of Birth
Address *
Phone (Main) *
Phone (Main)
Phone (Other)
Phone (Other)
Client Preferences
Preferred methods of contact *
What is your client's preferred method of contact?
Does the client choose to identify as having a disability? *
(e.g. service dog, frequent breaks, enlarged print, etc)
Income Assistance
Is the client on income assistance? *
Case Worker Information
Referring Case Worker
Referring Case Worker
Phone Number
Phone Number
Our commitment is to ensure that case managers are informed of any programs clients choose to attend.
Please call (902) 429-5878 for additional information.
Is the client connected to: *
Does the client have a criminal record? *
Does the client currently receive counselling or other mental health services? *
Is the client medically cleared to work? *
Have you ever been put off work by a doctor due to medical reasons?
Program(s) referring to: *
(Check as many as you wish)