Suite 103 – 121 Willowdale Avenue Phone: 416-229-1680

Toronto, ON, M2N 6A3 Fax: 416-229-1681; www.ldatd.on.ca

YIELD INTAKE FORM Confidential Document When Filled Out

PARTICIPANT PROFILE:
Gender: Female  Male  Undisclosed 
First Name Last Name
Address
Postal Code Email
Date of
Phone
Birth(mm/dd/yy)
Other language(s)
First Language
spoken
Citizenship Status
Emergency Contact Phone

Relationship Email

EDUCATION / TRAINING
Less than Grade 12  College Diploma  Apprenticeship 

University Degree  Trade School 

Completed High School 
Specify: Certificate / Professional Development / Affiliations
Graduate Degree _____________________________________________

PROFESSION/EMPLOYMENT
 No previous Canadian  Contract/Part Time
 Volunteer  Never worked
experience  Seasonal
 Employed (field: )  Trades  Other
 Self-employed
 (Years: ) (please Specify: ) (please specify: )
CAREER GOALS /
Short term: Long term:

REFERRAL SOURCE INFORMATION

How did you hear about the YIELD program?

 Friends/family  LDATD Website

 Media (please specify: )  Flyers/brochure

 School  Other LDATD department:

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  Other:

Services Required
Education  Health  Legal  Employment 
Financial Assistance
Social Assistance  Family Support  Community connection 

Language  Other  Explain: _____________________________________________

MEDICAL INFORMATION

Physician name/ phone

Physician address

Any allergies (please specify)

OHIP number

BARRIERS/CHALLENGES
 Learning Disability  Allergic Reactions  Personal Issue
 Speech Impairment  Behavioral Problems  Attendance/ Commitments
 Visual Impairment  Ongoing Treatments  Scheduling
 Hearing Impairment  Psychiatric Problems  Children & Daycare
 Lack of Job Searching Skills  Travel Assistance  Mental Health
 Community Connection  Literacy/Language  Access Community Services
 Other Specify:

Special Needs or Supportive Assistance:

OFFICE USE ONLY:

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CONSENT (√)

□ I hereby give permission to LDATD-YIELD to contact me and deliver agency information to my email address and
understand I could withdraw my consent at any time.

PARTICIPANT CONSENT TO RELEASE INFORMATION & CONSENT TO PHOTOGRAPHS, VIDEOTAPE

RECORDING, FILM AND INTERVIEW

I hereby give my consent for Learning Disabilities Association of Toronto District to exchange information regarding my
eligibility for participation in YIELD and other LDATD Programs. I also acknowledge that the information here is collected and
administered in accordance with the Privacy Act and may be used by Alternate Service Providers for better service provision.

(Print Participant Name) _______________________ Participant Signature___________________________________

______/_______/_________ (Date)
day month year

I, also give Learning Disabilities Association of Toronto District (LDATD), permission to photograph, videotape, make an
audiotape of, film and / or interview myself, and to publish said photographs, videotapes, audiotapes, films and / or
interviews in the LDATD publications / materials, including marketing and promotional materials and LDATD’s official website
for current and future use.

The photographs (including negatives), videotapes, etc. shall constitute the exclusive property of LDATD and may be
reproduced by LDATD and anyone it has authorized, without compensation or payment to the individual(s) concerned or any
other person.

_____________________________ ______/_______/_________ (Date)

Participant Signature day month year

_____________________________ ______/ _______/ ________ (Date)

Parent/Guardian Signature day month year

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