Report an Adult Day Program Absence

"Required" indicates required fields

Client NameRequired
Caregiver NameRequired
DD dash MM dash YYYY
DD dash MM dash YYYY
Adult Day Program Location:Required
Reason for AbsenceRequired
Would you like a staff member to follow up with you?Required
Permission to SubmitRequired
Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking “I agree” you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.