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Application for TIL Services
"
*
" indicates required fields
Step
1
of
7
14%
Please confirm the following applicant's information
*
If eligible, check all 3 boxes below and click the 'Next' button.
I am age 19 or older
I have limited mobility due to a permanent physical disability
I am a resident of British Columbia
You must meet the 3 eligibility requirements above to apply. If you have any questions, or require assistance completing this application, please contact us directly at
1-604-326-0175
.
You can also complete this application using the
Printable application form (pdf).
This application is being submitted by
*
Applicant
Alternate Contact of Applicant
Referring Therapist of Applicant
Applicant's Name
*
First
Last
Date of Birth
*
MM/DD/YYYY
MM slash DD slash YYYY
Email
Primary Phone
*
Secondary Phone (Optional)
Applicant's Current Residence
Address
*
Street Address
City
Postal Code
Is this a facility?
Yes
No
Facility Name
Medical Information & Coverage
Medical Diagnosis
*
Onset/Reason
Referring Therapist
Therapist Email
Therapist Phone
Therapist Phone Extension #
Therapist Address
Facility/Organization
Street Address
City
Postal Code
Does applicant have ICBC/WCB Coverage?
*
ICBC
WCB
None
ICBC/WCB Claim#
Case Manager Name
Phone
Fax
Email
Applicant's Alternate Contact
A family member, partner, caregiver, friend, etc.
Alternate Contact Name
*
Relation to Applicant
*
Alternate Contact Phone
*
Alternate Contact Email
Alternate Contact Home Address
*
Street Address
City
Postal Code
Environmental Control and Home Automation
Does applicant have any environmental controls at present?
*
Yes
No
Please describe your current environmental controls
Describe any smartphones, tablets, or smart home automation devices currently used by applicant
What devices does applicant want to control from bed and/or wheelchair?
*
Describe barriers/challenges applicant faces when using these devices
*
What technology, switches or switch placement will best assist the applicant?
If unknown, leave blank
Consent
*
I authorize the Technology for Independent Living program, and/or its representatives to release to or obtain from such agencies, individuals, medical centres or hospitals as are concerned with my medical rehabilitation, any and all pertinent information which may be necessary to assist in providing me with medical rehabilitation services.
I declare that any information which has been provided in order for the Technology for Independent Living program to determine my eligibility to receive services at no cost, or at reduced cost, is true to the best of my knowledge and belief.
I understand that all such information will be treated as confidential and privileged, and used only for the purpose of assisting my medical rehabilitation.
I am nineteen years of age or older.
I understand that, upon my approval for assistance from Technology for Independent Living, I will automatically become a member of Technology for Living.
By checking this box I confirm that I agree to the Terms and Conditions
Consent
*
The applicant authorizes the Technology for Independent Living program, and/or its representatives to release to or obtain from such agencies, individuals, medical centres or hospitals as are concerned with their medical rehabilitation, any and all pertinent information which may be necessary to assist in providing them with medical rehabilitation services.
The applicant declares that any information which has been provided in order for the Technology for Independent Living program to determine their eligibility to receive services at no cost, or at reduced cost, is true to the best of their knowledge and belief.
The applicant understands that all such information will be treated as confidential and privileged, and used only for the purpose of assisting their medical rehabilitation.
The applicant is nineteen years of age or older.
The applicant understands that, upon their approval for assistance from Technology for Independent Living, they will automatically become a member of Technology for Living.
By checking this box I confirm that I have discussed with the applicant, and they have agreed to, all terms and conditions outlined above.
Email
This field is for validation purposes and should be left unchanged.
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