Self-Determination Training Survey

1.Are you able to attend at least one of our upcoming trainings on May 14th or May 15th?

Yes

Yes - But Only on Facebook Live

No

2.Which site will you be attending

Stockton

Modesto

Facebook

None

3.Contact Information (Minimum Required: Your Name, Consumer's Name, and Consumer's Birthdate and or UCI#)

Name

Consumer's Name (if you are a family member of a consumer)

Consumer's UCI # (this is not required but can be found on the IPP)

Address

City/Town

State/Province

ZIP/Postal Code

Consumer's Date of Birth

Email Address

Phone Number

4.Are you already on the "Interested List"

Yes

No

Don't Know

5.Would you like to be added to the interested list?

Yes

No

Not sure yet

6.Do you need Spanish Language translation services?

Yes

No

Self-Determination Training