Community Service Options, Inc.

1. How many people are in your household (include yourself)?

2. How many people in your household have a diagnosed disability?

3. Please list the number of people and their ages who have a disability.

	#	age
Learning disability
Alcoholism/drug abuse
Emotional disorder
Mental retardation
HIV/AIDS
Mental illness
Deaf/hard of hearing
Blind/Visual impaired
Physical disability
Traumatic Brain Injury
Cognitive / Autism / Autistic Type
Speech/language
Developmental disability

How many people in your family have and use assistive devices?

5. How many people in your family need respite services?

6. How many people in your family need residential services?

7. What is your story? What is your experience/ issue/need with regard to residential and/or respite services?

8. How many people in your family need supervised daily treatment or activity?

What is your experience/issue/need in obtaining these services?

9. How many people in your household are employed?

10. Is the person with a disability employed?

11. Does the person with a disability get SSI?

12. Is the disability an obstacle for anyone in the household’s getting and keeping employment?

Explain

13. What do you want to say?

Tell Us About You

What is your name?

Address

Telephone number

Email Address