Date received: Approved:
Inclusion Nova Scotia
3845 Joseph Howe, Suite 101
Halifax, NS B3L 4H9
Health and Wellness COVID-19 Relief Referral Form
The purpose of this relief fund is to support vulnerable populations impacted by COVID-19. Our focus will be
supporting those who identify as having an intellectual disability and their families as well as those who
struggle with mental health or addictions.
Potential requests might look like:
Provide gift cards from grocery stores or gas stations.
Provide taxi fares for medical or other necessary appointments.
Provide tablets or phones to families who are living apart from loved ones to support communication.
Provide materials to support recreational activities that can be done at home such as jigsaw puzzles,
art supplies and board games.
Provide emergency funds upon request for prescription medication and/or other essential items.
To be responsive to the individual needs of Nova Scotians who have been impacted by the COVID-19
Pandemic: We will consider any reasonable request for support which will ease isolation and effects of
poverty for individuals with intellectual disabilities and their families.
Complete both boxes if you’re submitting a referral on somebody’s behalf. If you are requesting funds
for yourself only fill out the second box.
Name of Organization/Person making the referral?
What is the contact information for Organization/Person making the referral?
Phone number Email
The name of the person the funds are intended for?
What is the contact information for the person requesting funds?
Phone number Email
What city/town does the individual reside in?
Does the individual who would be receiving funds identify as having an intellectual disability or struggling
with mental health or addictions?
How much money is being requested?
Why are funds being requested?
Please forward requests to firstname.lastname@example.org or call 902-469-1174 ex 4 for more information.
This funding is made possible by the Nova Scotian Department of Health and Wellness.