**Required Fields

**Name:

**Address:

Phone #:

County:

Birth Date:

Sex:
Male Female

E-Mail:

How did you become aware of the Catskill Center for Independence?

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**Disability
(Check all that apply)

A. Blindness	M. HIV/AIDS
AA. Low Vision	N. Epilepsy
B. Deafness	O. Autism
BB. Hard of Hearing	P. Spina Bifida
C. Orthopedic	Q. Muscular Dystrophy
D. Mental Retardation	R. Congenital Birth Anomaly
E. Mental Illness: Specify:	S. Amputation
F. Traumatic Brain Injury	T. Cerebral Palsy
G. Learning Disability	U. Environmental & Related
H. Reserved	V. Neuromuscular
I. Spinal Cord Injury	W. Other (Physical): Specify:
J. Back Injury	X. Other (Sensory): Specify:
K. Emotional/Behavioral Disabilities	Y. Multiple Disabilities
L. Substance Abuse

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Ethnic Background

(Optional)

Do not wish to respond	White	Black	American Indian
Alaskan native	Hawaiian Indian	Asian/Pacific	Hispanic

Other:

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Employment Status

Employed full time	Employed part time	Seeking work
Unemployed, not seeking work	Student	Retired

Participating in segregated work or day program setting

Other (specify):

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Education Status
(Check the highest level obtained)

K-8	Some high school
Completed high school	Some college
Business, trade, vocational school	Completed two year undergraduate degree
Completed for year undergraduate degree	Completed post graduate degree program

WE ARE OBLIGATED BY STATE LAW TO PROVIDE THIS INFORMATION TO THE NEW YORK STATE EDUCATION DEPARTMENT UPON REQUEST.

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INDIVIDUAL CONSUMER NEEDS ASSESSMENT

Dear Consumer:

Please take a moment and indicate any of the services listed below that you would like information about or in which you need assistance. This helps us provide you with the services that are most beneficial to you.

PLEASE CHECK AS MANY AS NECESSARY

INFORMATION ABOUT THE CENTER	TDD RELAY SERVICE
TRANSPORTATION, MOBILITY TRAINING	SHARING PROBLEMS OR CONCERNS WITH ANOTHER PERSON WITH A DISABILITY
EMPLOYABILITY SKILLS TRAINING	HELP WITH LEGAL RIGHTS OR LEGAL ISSUES
EDUCATION/TRAINING REFERRALS	MEDICAL ASSISTANCE - OBTAINING HELATH CARE IN THE HOME
HELP WITH APPLYING FOR BENEFITS SUCH AS MEDICAID, SSDI, SSI, ETC.	RECREATION, INCREASING SOCIALIZATION
HELP WITH LOCATING ACCESSIBLE HOUSING	INTERPRETER REFERRAL
HELP WITH BUDGETING	LEARNING SIGN LANGUAGE
LOCATING OR STARTING A SUPPORT GROUP	VOTER REGISTRATION
HELP WITH HOME MODIFICATION TO MAKE RESIDENCE MOR ACCESSIBLE	EQUIPMENT LOAN OR ADAPTIVE/ASSISTIVE TECHNOLOGY
PROBLEMS WITH PUBLIC BUILDING/BUSINESS ACCESSIBILITY	OTHER ASSISTANCE (SPECIFY):
PERSONAL CARE ATTENDANT REFERRAL

PLEASE FEEL FREE TO INCLUDE ANY ADDITIONAL COMMENTS/CONCERNS:

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM. A CENTER REPRESENTATIVE WILL CONTACT YOU TO EXPLORE THE AREAS IN WHICH YHOU HAVE REQUESTED INFORMATION OR ASSISTANCE. PLEASE FEEL FREE TO CONTACT US AT ANY TIME FOR ANY OTHER ASSISTANCE YOU MAY REQUIRE.