Wo55 Intake / Referral Form | Re-Imagine Ontario

This form is to be used for any senior, who is 55 or older, who wants to participate in the Senior's programs offered by Re-Imagine Ontario such as Wo55 (West of 55) or Seniors on the Go (medical transportation service).

This is also used for volunteer drivers to register in the Seniors on the Go program.

Birthday

To more easily change the year, click on the year and then type in the number. Example, click on 2025 and type in 1956.

Address

Street address and unit/apartment (if applicable)

City / Region

Oakville

Burlington

Georgetown

Acton

Mississauga

Aldershot

Milton

Other

Mobile Number

We will use this number to send you notifications by SMS for Seniors on the Go appointment bookings and up-coming events.

Leave this blank if you don't have or don't use email. If you put an email address then we will use this email address to send you notifications about your appointment booking if you are using Seniors on the Go.

Ethnicity

Indigenous

White European

White North American

Other Asian

Latino

Mixed Heritage

Middle Eastern

Black African

Black - Caribbean

Black - North American

South Asian

Other

Your Primary Language

French

Arabic

English

Mandarin

Other

Residency Status

Canadian Citizen

Permanent Resident

Refugee

Arrival Date Into Canada

What was your arrival date into Canada as a refugee?

Emergency Contact Information

Emergency Contact Name

Relationship to Senior

The relationship of this emergency contact to the senior (Son, Daughter, Spouse, etc.)

Emergency Contact Phone Number

Living Arrangement

With Spouse / Partner

Assisted Living

Live Alone

With Family / Friend

Other

Do you smoke?

Yes

Do you have any pets?

Yes

Do you have access to the Internet?

Yes

How do you access the Internet?

Smartphone (iPhone or Android)

iPad or Tablet

Computer or Laptop

Do you use any in-home services?

Medical Information

Please provide notes about your current medical situation especially if it will impact your use of the Seniors on the Go program.

Mobility

Specifically any information that would help our Seniors on the Go drivers.

Vision Impairment

Please specify especially if it would help our Seniors on the Go drivers to better assist you.

Hearing Impairment

Please specify especially if it would help our Seniors on the Go drivers to better assist you.

Do you want to use Seniors on the Go?

Yes

Perhaps in the future

Select option "Yes" if you would like to use this service or "Perhaps in the future" if this is a service you might consider using in the future.

Please explain why you need this service

Reasons why you might want to use this in fhe future or the reasons you need to use the Seniors on the Go service now.

Your Income Situation

Approximate Annual Income

Are you completing this form for yourself or are you the Senior's Substitute Decision Maker (SDM)?

Myself

SDM on behalf of Client

SDM has provided consent referral to Re-Imagine Ontario

Yes

If you need this form, please send us an email.

Referee's Information

Is this form being completed by a referee?

Yes

Referee's Title

If you are a referee from an organization please put your job title. If you are a friend or family filling out this form then please put your relationship such as friend, son, daughter, etc.

Referring Organization's Name

Only required if the referee is also an organization.

Referee's Phone/Mobile

Emergency Contact Information

About You

Seniors on the Go

Referee's Information