*1.Are you...?(Required.)

A person with a disability and/or chronic health condition

A parent or guardian of a person who has a disability

A caregiver or direct service worker of a person who has a disability

A community advocate or service provider

Other (please specify)

*2.What New Mexico County do you live in?(Required.)

*3.For this question, please check the services you (or the person you support or assist) have NEEDED in the last 12 months.
Mark all that apply.(Required.)

Advocacy or Self-Advocacy
how to ask for help and speak to others about your needs

Mental Health Services

Employment or Vocational Services
training, resources, and supports to get and keep a job

Independent Living (IL) Skills Training
training to learn how to live on your own, such as cooking, paying bills, getting around your town

Information and Referral
getting information and resources about services in your community for people with disabilities

Peer Support
information and support given to you by another person with a disability

Disability Rights or Law Services
help understanding your rights or legal issues related to disability

Computer or Technology Training

Durable Medical Equipment or DME
help with getting or repairing DME, such as wheelchairs, walkers, crutches, oxygen

Personal Assistance Services
help in your home with personal care or daily activities because of your health or disability - this is sometimes also called a personal care attendant, support worker or caregiver

Social or Recreation Support
help when spending time with family or friends, going to movies, going out to eat

Transportation to get around your community

Assistive Technology or AT
equipment, software or technology product used to help you live more independently, such as a screen reader or magnifier, AAC, speech recognition software, TTY

Other (please specify)

None of the above

4.If you checked yes to any of the services above as needed, did you receive those services?

Yes

No

5.What barriers make it difficult for you to get the services you need to live more independently?
Mark all that apply.

The services I need are not available where I live

I do not have reliable or accessible transportation

I do not have money to pay for gas or transportation

Services are not provided in my primary language

I cannot leave my home because of accessibility issues

The place I need services from is not accessible

I do not experience barriers to getting the services I need

Other (please specify)

6.What barriers prevent you from taking part in events and activities outside your home and in the community?
Mark all that apply.

Lack of accessible and affordable housing

The places I would like to go are not accessible

Communication Access (need for ASL interpreter, Braille, large print, or CART for example)

Attitudes or discrimination

I need Assistive Technology (AT) or adaptive equipment to participate in my community

I don't have the money or personal finances

I do not have reliable or accessible transportation to get to place I want to go

I do not experience barriers to taking part in activities outside my home

Other (please specify)

7.Have you (and/or someone you support or assist) contacted a Center for Independent Living (CIL) in New Mexico for information, assistance, or services during the past 12 months?

Yes

No

I did not know or hear about CILs before now

8.Please choose the issues you think are most important to people with disabilities in New Mexico. Mark all that apply.

Advocacy

Assistive Technology

Employment/Vocational Services

Housing Assistance

Independent Living Skills Training

Long Term Care Diversion

Peer Support

Personal Assistance Services

Transportation

Durable Medical Equipment

Social or Recreation Support

Youth Transition Services