Find My Money Questionnaire
Section 1 of 11
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Website (leave blank)
Contact Information
First Name
Last Name
Gender
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Female
Male
Other
Marital Status
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Single
Common-law
Married
Separated
Divorced
Widowed
Email
Mobile Phone
Street Address
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
How did you find out about us?
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Referral
Workshop or Seminar
Tik Tok
Facebook
LinkedIn
Instagram
Google
Exceedia Website
Other
Referrer's Name
Do you have a disability?
Select...
No
Yes
Not sure
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Family Information
Do you have children under 18 years old?
Select...
No
Yes
Not sure
Does your child have a disability?
Select...
No
Yes
Not sure
Do you have adult children (over 18 years old)?
Select...
No
Yes
Not sure
Does your adult child have a disability?
Select...
No
Yes
Not sure
Are you taking care of relatives?
Select...
No
Yes, My parents
Yes, My grandparents
Yes, Other relatives
Does this relative have a disability?
Select...
No
Yes
Not Sure
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Recent Circumstances
Who prepares your taxes?
Select...
I either file myself / my friend helps
I pay a professional
I have never filed taxes
My taxes are not filed up to date
I have been out of the country (Canada) in the last 5 years
What is your marital status when filing taxes?
Select...
File as single
File together with spouse
File separately from spouse
In the last 5 years, which of these income situations apply?
I have moved interprovincially for work or school
I have moved internationally for work or school
I have made a career change
I started a business
I closed a business
I attended post-secondary school
I was unemployed
None of these apply
In the last 5 years, which of these life events applied?
My marital status changed
I have or had a dependent (children)
I sponsored or am sponsoring my family to Canada
I am or was caring for a sick spouse or parent
I am or was caring for a sick child
I moved from another province
Parent/Spouse has passed away
None of these apply
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Current Circumstances
Describe your current situation
I feel like I am making good money but I cannot seem to save
I was recently divorced or widowed
I am taking care of aging parents
I want to make sure I do not mess up my future taxes
I have a recent career or job change
I have recently become seriously ill
I work from home
My finances are disorganized and I am overwhelmed
I often travel for work or business
My situation has become more complicated
I am currently satisfied with my financial situation
None of these apply
How do you currently receive income?
Employee
Self-employed
Rental Property
Investment Income
Pension - Employer
Disability Benefits
Social Assistance
Old Age Security
Canada Pension Plan
Alimony or Palimony
Personal Income
Select...
Less than $50,000
$50,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000 - $300,000
over $300,000
Household Income (including spouse)
Select...
Less than $50,000
$50,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000 - $300,000
over $300,000
Have you had any difficulty with your credit in the last 10 years?
Select...
I do not have any credit difficulties
I have difficulty paying my bills on time
I have/had an Orderly Repayment of Debt Order
I have/had a consumer proposal order
I have/had a personal bankruptcy
I have/had a corporate bankruptcy
I have/had a court judgement that I have to make payments
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Financial Planning
Where do you go to get financial advice?
Select...
Social Media
Internet Research
I am a financial professional and I manage my own advice
I read articles from the financial industry
I have a trusted friend / family member
I pay a financial professional
I don't get advice from anyone
What plans do you have for the next 12-24 months?
Wedding
Purchase Real Estate
Sell Real Estate
Expand my family
Change employment
Start a business
Receive inheritance
Pay for post-secondary
Pay off large loan
Save more money
Invest more money
Borrow more money
Start a financial plan
Retire / Stop working
None
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Disability Tax Credit Pre-Qualifier
Who would you like to assess? (One questionnaire per person)
Select...
Myself
My Spouse
My Child(ren)
My Parent(s)
My Grandparent(s)
A Relative
Spouse's Name
Child's Name
Parent's Name
Grandparent's Name
Relative's Name
Is this individual currently using any of these medical professionals?
Medical Doctor
Nurse Practitioner
Optometrist
Audiologist
Occupational Therapist
Physiotherapist
Psychologist
Speech Language Pathologist
None of the above
Medical Records - Which professionals have medical records for your condition?
Medical Doctor
Nurse Practitioner
Optometrist
Audiologist
Occupational Therapist
Physiotherapist
Psychologist
Speech Language Pathologist
None of the above
Which medical professionals are willing or able to sign your completed application?
Medical Doctor
Nurse Practitioner
Optometrist
Audiologist
Occupational Therapist
Physiotherapist
Psychologist
Speech Language Pathologist
None of the above
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Hearing, Speaking & Vision
Hearing: Which of these situations apply?
You cannot hear spoken conversation with a familiar person in a quiet setting
It takes you three times longer to hear and understand a familiar person speaking in a quiet setting
You are completely deaf in both ears
None of the above
How long have you had this hearing condition?
Select...
Less than 12 months
More than 12 months
Is your hearing condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your condition likely to improve to the extent that you are no longer impaired?
Select...
No
Unsure
Yes
Not applicable
Speaking: Which of these situations apply?
You stutter
You have difficulty pronouncing and enunciating words
You are not speaking at the appropriate development level for your age
You have limited vocabulary compared to others your age
None of the above
Speaking: Which of these conditions apply?
You have autism and are non-verbal
You have / had a stroke and it affects your ability to speak
You have dysarthria
You have / had a brain tumor that affects your ability to speak
None of the above
How long have you had this speaking condition?
Select...
Less than 12 months
More than 12 months
Is your speaking impairment condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your speaking condition likely to improve to the extent that you are no longer impaired?
Select...
No
Unsure
Yes
Not applicable
Vision: Which of these situations apply?
You have visual acuity less than 20/200 or 6/60
You have clouding in the lens of your eyes
Your field of vision is 20 degrees or less
You have optic nerve damage
You have damage to your retina
None of the above
Vision: Which of these conditions apply?
I have cataracts
I have glaucoma
I have macular degeneration
I have diabetic retinopathy
None of the above
How long have you had this vision condition?
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Less than 12 months
More than 12 months
Is your vision impairment condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your vision condition likely to improve to the extent that you are no longer impaired?
Select...
No
Unsure
Yes
Not applicable
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Elimination
Do you have any of these digestive conditions?
Colorectal Cancer
Irritable Bowel Syndrome
Ulcerative Colitis
Crohn's Disease
None of the above
Elimination: Which of these situations apply?
You experience leaking urine when coughing sneezing laughing or running
You frequently fail to reach the toilet in time
You wear incontinence briefs or pads due to urinary incontinence
You frequently experience an urgent need to move your bowels
You frequently experience diarrhea
You frequently have sudden strong urge to urinate
You have an ostomy
You have frequent nighttime awakenings to use the bathroom
None of the above
How long have you had these bowel or bladder conditions?
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Less than 12 months
More than 12 months
Is your bowel or bladder condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your condition likely to improve to the extent that you are no longer impaired?
Select...
No
Unsure
Yes
Not applicable
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Feeding & Life Sustaining Therapy
Feeding: Which of these situations apply?
You are unable to prepare your food or feed yourself
You have difficulties with swallowing
You have difficulties with holding utensils to feed yourself
You require a feeding tube to feed yourself
None of the above
Feeding: Do you have any of these conditions?
Oral dysphagia
Pharyngeal or oropharyngeal dysphagia
Esophageal dysphagia
Crohn's disease (in severe cases)
Gastrointestinal cancer
Intestinal failure
Bowel obstruction
Ulcerative colitis
None of the above
Feeding: Do you have any of these mental diagnoses?
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Avoidant restrictive food intake disorder
Pica
Rumination disorder
None of the above
How long have you had this feeding condition?
Select...
Less than 12 months
More than 12 months
Is your feeding condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your feeding condition likely to improve?
Select...
No
Unsure
Yes
Not applicable
Life Sustaining Therapy: Which of these situations apply?
You need Chest physiotherapy
You need Tube feeding
You need 24 hour oxygen therapy
You need intermittent oxygen therapy
You need Peritoneal dialysis
You need Hemodialysis
You need multiple daily insulin injections
You need an insulin pump
None of the above
Life Sustaining Therapy: Do you have any of these disorders?
You have Cystic Fibrosis
You have Phenylketonuria (PKU)
You have End-stage renal disease
You have Type 1 Diabetes
You have Type 2 Diabetes
None of the above
How long have you had this life sustaining therapy condition?
Select...
Less than 12 months
More than 12 months
Is your condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your condition likely to improve?
Select...
No
Unsure
Yes
Not applicable
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Walking & Dressing
Walking: Which of these situations apply?
You are unable to walk on your own
You have impaired balance
You have pain when you walk 100 meters
You have shortness of breath during or after any physical activity
You have to take frequent breaks when walking due to pain
You have swelling and stiffness in the joints
You have loss of cartilage that has made it difficult to maneuver your body
You have weakened muscles that limits your movement
You experience frequent dizziness that causes you to lose your balance
You do not leave your home because movement is strenuous
You have difficulty sitting down or standing up without assistance
You cannot run
You cannot jump
None of the above
Walking: Do you have any of these conditions?
You have or had hip replacement
You have or had knee surgery
You have or had back surgery
You had a stroke
You have paralysis
You have cerebral palsy
You have multiple sclerosis
You have muscular dystrophy
You have arthritis
You have or had spinal cord injury
None of the above
How long have you had this walking condition?
Select...
Less than 12 months
More than 12 months
Is your walking condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your walking condition likely to improve?
Select...
No
Unsure
Yes
Not applicable
Dressing: Which of these situations apply?
You experience pain in your upper extremities
You have a limited range of motion
You have partial paralysis
You have mechanical allodynia
You require assistance to get dressed
You have balance issues that affect your ability to put on shoes or pants
You have tremor or dyskinesia
None of the above
Dressing: Which of these conditions apply?
You have Parkinson's
You have fibromyalgia
You have carpal tunnel
You had a stroke that caused partial paralysis
None of the above
How long have you had this dressing condition?
Select...
Less than 12 months
More than 12 months
Is your dressing condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your dressing condition likely to improve?
Select...
No
Unsure
Yes
Not applicable
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Mental Functioning
Mental Function: Adaptive Functioning
You have trouble planning or carrying out a task because you can't visualize the finished product or goal
You have difficulty motivating yourself to start a task that seems difficult or uninteresting
You become frustrated when things don't go as planned and can quickly become angry
You are easily overwhelmed and unable to follow through with day to day tasks
You frequently forget daily hygiene routines like showering bathing brushing your teeth
You have trouble explaining your thought process clearly
You struggle with thinking before you talk causing you to blurt out the first thing that pops in your head
None of the above
Mental Function: Judgment
You frequently go out in winter without a jacket despite it being below freezing
You consider yourself a people pleaser going above and beyond to get on someone's good side
You often don't think about the consequences of your actions
You are easily overwhelmed and unable to follow through with day to day tasks
You struggle with thinking before you talk
None of the above
Mental Function: Perception of Reality
You have recurrent persistent thought impulses or images that cause you distress
You experience ritualized excessive repetitive behaviours such as hand washing
You experience auditory or visual hallucinations
You experience delusions
None of the above
Mental Function: Attention/Concentration/Memory
You often misplace things and find them in odd places
You become absorbed in things or tasks that interest you sometimes forgetting other obligations
You misplace or lose items multiple times a day
You struggle with binge eating impulsive spending excessive drinking or gambling
When you read something you usually end up going back to re-read the prior section
You have difficulty remembering important information like your address or names of people
You have a poor sense of time and often mix up dates
You are easily distracted when completing tasks
None of the above
Mental Function: Emotion Regulation
You assume the worst in commonplace interactions
You experience sudden intense bouts of extreme sadness when you think you have been rejected or criticized
People have complained that you over-react to minor inconveniences
You avoid meeting new people or trying new things because your fear of rejection is so strong
You get extremely upset when a friend is late or cancels plans
You struggle with anger and tend to act in a sarcastic irritable manner
None of the above
Mental Function: Do you have any of these conditions?
Borderline Personality Disorder
PTSD Post Traumatic Stress Disorder
Depression and/or Anxiety
OCD Obsessive Compulsive Disorder
ADHD
Schizophrenia
None of the above
How long have you had this condition?
Select...
Less than 12 months
More than 12 months
Is your condition present all the time?
Select...
Multiple times a year
Less than 90% of the time
At least 90% of the time
All the time
Is your condition likely to improve?
Select...
No
Unsure
Yes
Not applicable
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