Mercury Disability Board

Assessment Request Form

Please fill out the following form to begin your assessment process.

Assessment Request Form
I'm completing Assessment Request Form for

Claimant Information (Child/Youth)

Name
Name
First Name
Middle Name
Last Name
Gender
Address
Address
City
State/Province
Zip/Postal
Country
Identify Community Affiliation:
Consent
Is the claimant under the age of 16?

Parent / Guardian Consent

(If the person above is under the age of sixteen (16), a parent or legal guardian must complete section below.)
Name
Name
First Name
Last Name

Claimant Information (Adult)

Name
Name
First Name
Middle Name
Last Name
Gender
Address
Address
City
State/Province
Zip/Postal
Country
Identify Community Affiliation:
Consent

Additional Information Request

Name
Name
First Name
Middle Name
Last Name
Name at Birth if different from above
Name at Birth if different from above
First Name
Last Name
Name of Mother
Name of Mother
First Name
Last Name
Name of Father
Name of Father
First Name
Last Name
Name of Grandmother (your mother's side)
Name of Grandmother (your mother's side)
First Name
Last Name
Name of Grandfather (your mother's side)
Name of Grandfather (your mother's side)
First Name
Last Name
If known, please provide address of residence in community.
If known, please provide address of residence in community.
City
State/Province
Zip/Postal
Country

Alternatively, a printable PDF forms for the new reformed Assessment process application form can be downloaded from the following links:

Child/Youth Assessment Request Form
Adult Assessment Request Form
ARF Additional Information Request Form
ARF Receipt Checklist and Process