Service Requests Survey

1.What County are you seeking services?

2.Services Needed

I&R Services - Connecting individuals to the services and supports needed in their community.

Peer Support - Mentoring and supporting individuals with shared experiences to create empowerment and independence.

IL Skills - Teaching individuals the skills needed to be more independent and have greater control over their lives.

Advocacy - Preparing individuals to stand up for themselves and access the supports they need.

Youth Transition - Assisting youth with disabilities to prepare for adult life. This can consist of education, employment, or community participation.

Diversion - Critical services aimed at keeping individuals with disabilities from having to enter an institution and allowing them to remain in the community.

Nursing Home/Institutional Transition - Assisting individuals in an institutional setting, such as a nursing facility, to transition to community-based living.

Other (please specify)

3.Please describe what is needed from a CIL?

4.If you are willing to share how these services are needed please complete the below information

Name

City/Town

Email Address

Phone Number