Thank you for completing this form. By doing so, you agree the Louisiana Developmental Disabilities Council can share your story with the National Association of Councils on Developmental Disabilities (NACDD) as well as state and federal policymakers. Your story will be used for advocacy purposes to show our policymakers the importance of Medicaid services for people with disabilities and their families.

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* 1. First Name

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* 2. Last Name

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* 3. City You Live In

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* 4. Zip Code

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* 5. Tell us a little bit about yourself. (e.g. Do you live in the community; Do you have a job or volunteer somewhere; Which waiver or other Medicaid services do you have, etc.)

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* 6. How do you use your Medicaid services? Having Medicaid makes it possible for you to….. (e.g. Do you need a caregiver to help you get up in the morning or get ready for school, work, or a day out in the community; Do you use a worker to help with your medications or doctor’s appointments; Does your Medicaid cover special services that really help you; etc.)

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* 7. What would your life be like if Medicaid were cut and you had less supports and help than you do now? (e.g. Could you remain in your home or at your job; Would you miss doctor’s appointments or not be able to take medications; Do you have things you do daily that you can't do without the help of a support worker; etc.)

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* 8. Is there anything else you would like to share?

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* 9. Having a photo to share with your story makes your story more personal to policymakers. If you would like, please upload a photo of yourself or the person(s) you support.

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