If you need help, please call: Cate Adelman at (815) 973-6776

* 1. Contact information

* 2. What is the best way to contact you?

* 3. Age (years):

* 4. Gender:

* 5. To be sure we include people with different support needs in our Focus Group, which of the following best describes you.  

Are you a person… (you can select multiple)

* 6. If you are NOT a person with a disability or a family member of a person with a disability, why do you want to participate in a Focus Group?

* 7. Is there anything you need that will make it easier for you to participate?

* 8. What meeting locations and times work for you?

* 9. If you are unable to attend, is there anything you would like to share about eligibility determination, assessments, case managers, or choice involving supports and services?