Contact and Information Form Personal Information: First Name*: Last Name*: Home Phone*: Work Phone: Cell Phone*: Email*: Please Contact Me By*: home phonework phonecell phoneemail Reason for Contact (Select All That Apply)*: My doctor told me to have my ability to drive evaluatedThe Ministry of Transportation requires I have my driving ability evaluatedI am concerned about my ability to drive safelyA loved one or care giver is concerned about my ability to drive safelyI am a new driver with disabilities and am interested in driver trainingI was a driver but an accident or illness have affected my ability to driveI am a loved one or caregiver and concerned about a person’s drivingI am a caregiver or loved one contacting you as a referralI am a health care professional looking for more information or to arrange an educational inservice.Other (please explain) Other: Comments: