CDCI Consumer Referral Form Survey

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* 2. Contact Information

Name

Address

City

State

Zip Code

County

Phone Number

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* 3. Can CDCI contact you by email?

Yes

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* 4. Date of Birth

Date

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* 5. Gender

Male

Female

Other

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* 6. Which of the following best describes your race?

White or Caucasian

Black or African American

Hispanic or Latinx

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

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* 7. What is your ethnicity?

Hispanic or Latinx

Non-Hispanic/Latinx

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* 8. I am a...

person with a disability

family/friend

professional

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* 9. What best describes your disability?

Cognitive

Physical

Mental

Sensory

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* 10. If cognitive, which of the following best describes your disability?

Intellectual/Developmental

Traumatic or other brain injury

Autism

Learning Disability

Other (please specify)

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* 11. If physical, which of the following best describes your disability?

Spinal Cord Injury

Spina Bifida

Neuromuscular

Orthopedic

Cerebral Palsy

Epilepsy

Muscular Dystrophy

Amputation

Back Injury

HIV/AIDS

Environmental

Other physical

Other congenital birth anomaly

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* 12. If mental, which of the following best describes your disability?

Mental Illness

Substance Abuse

Emotional/Behavioral

ADHD

Other (please specify)

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* 13. If sensory, which of the following best describes your disability?

Blindness

Deafness

Deaf/Blind

Low Vision

Hard of Hearing

Other

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* 14. Have you worked with CDCI before?

Yes - If so, what year?

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* 15. Who referred you to our services?

Name

Organization (if applicable)

Email Address

Phone Number

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* 16. Please tell us which services you are seeking (check all which apply).

Advocacy/Legal Services

Architectural Barrier Services

Assistive Technology

Benefits Advisement

Children's Services

Communication Services

Counseling and Related Services

Employment Services

Family Services

Housing, Home Modifications, and Shelter

IL Skills Training and Like Skill Training Services

Information and Referral

Mobility Training Services

Peer Counseling Services

Personal Assistance Programs

Physical Restoration Services

Preventive Services

Prostheses, Othotics, and Other Appliances

Plan to Achieve Self-Support

Recreational Services

Rehabilitation Technology Services

Therapeutic Services

Youth/Transition Services

Vocational Services

Voter Registration

Other (please specify)

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* 17. Have you been affected by COVID and NYS PAUSE?

Yes

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* 18. Do you require assistance?

Yes

CDCI Consumer Referral Form

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* 1. Date of Referal

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* 2. Contact Information

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* 3. Can CDCI contact you by email?

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* 4. Date of Birth

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* 5. Gender

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* 6. Which of the following best describes your race?

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* 7. What is your ethnicity?

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* 8. I am a...

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* 9. What best describes your disability?

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* 10. If cognitive, which of the following best describes your disability?

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* 11. If physical, which of the following best describes your disability?

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* 12. If mental, which of the following best describes your disability?

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* 13. If sensory, which of the following best describes your disability?

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* 14. Have you worked with CDCI before?

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* 15. Who referred you to our services?

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* 16. Please tell us which services you are seeking (check all which apply).

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* 17. Have you been affected by COVID and NYS PAUSE?

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* 18. Do you require assistance?

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* 19. In which areas do you need assistance (check all which apply)?

CDCI Consumer Referral Form

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* 1. Date of Referal

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* 2. Contact Information

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* 3. Can CDCI contact you by email?

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* 4. Date of Birth

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* 5. Gender

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* 6. Which of the following best describes your race?

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* 7. What is your ethnicity?

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* 8. I am a...

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* 9. What best describes your disability?

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* 10. If cognitive, which of the following best describes your disability?

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* 11. If physical, ﻿which of the following best describes your disability?

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* 12. If ﻿mental﻿, which of the following best describes your disability?

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* 13. If ﻿sensory, which of the following best describes your disability?

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* 14. Have you worked with CDCI before?

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* 15. Who referred you to our services?

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* 16. Please tell us which services you are seeking (check all which apply).

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* 17. Have you been affected by COVID and NYS PAUSE?

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* 18. Do you require assistance?

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* 19. In which areas do you need assistance (check all which apply)?

* 11. If physical, which of the following best describes your disability?

* 12. If mental, which of the following best describes your disability?

* 13. If sensory, which of the following best describes your disability?