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1. Name

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2. Telephone Number

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3. Briefly describe the disability of the member of your household, and how it is affecting his or her use of our services:

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4. Please check the service(s) with which your household member is experiencing difficulty due to his or her disability.

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5. Are you aware of any devices or services that could help alleviate these difficulties?

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6. May we contact you further about accessibility issues?

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7. What is the best time and manner to contact you?

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