Eligibility Information for the DSO HNR

Thank you for your referral to the DSO HNR.

1. Please complete this form AND
2. Please attach a clear picture of all of the information listed below
☐ birth certificate (proof of age)

☐ health card (proof of residency)

☐ psychological report with adaptive and cognitive scores (proof of
developmental disability)
3. Please send the completed form and the documents to:
intake@dsohnr.ca or 4-140 King Street Hamilton ON L8N1B2
When we receive your information, we will review it and we will get back to you as soon
as we are able.
Applicant Information:
Date
First name
Last name
Full Mailing Address: Street name apt. #
City
Postal Code
Phone number
Email address
Date of Birth MONTH/DAY/YEAR
Mother’s birth last name
Do you make decisions on ☐ I make my own decisions
your own, or does
someone help you? ☐ Someone helps me with decision making:

Name of person:

Relationship to you:

Date of Birth (if family):

Phone number:

Address:

Email:
Can I call the person who ☐ Yes
helps you make decisions
if I have any questions
about this form or the
information you sent us?
Name of Person helping you apply
First name
Last name
Relationship to the person ☐ Parent, living with the person
applying for service ☐ Parent, not living with the person
☐ Sibling, living with the person
☐ Sibling, not living with the person
☐ Friend
☐ Primary Care Physician
☐ Community professional:
☐ Hospital:
☐ Other:
Full Mailing Address: Street name apt. #
City
Postal Code
Phone number
Email address

If you have any questions about this form, please email intake@dsohnr.ca or call
1-877-376-4674 ext. 340. We will get back to you as soon as we can; it can take up to
5 business days.