CONSUMER ELIGIBILITY To be eligible for Northern Nevada Center for Independent Living services, a person must experience a significant disability which limits their ability to function independently. In order to document that you are eligible for our services, please answer the following: 1. My primary disability is Required field Cognitive Mental/Emotional Physical Hearing Vision Multiple Disabilities Other 2. My disability(ies) substantially limits me from functioning independently in the following areas Required field Self-Care Mobility Education Employment Housing Other Type your disability here Required field The Services I am requesting will help me: Required field Improve my ability to function at home or in the community Maintain my ability to function in my family or community Obtain, maintain or advance in employment CONSUMER INFORMATION Last Name Required field First Name Required field Middle Initial Address Required field City Required field State Required field ZIP Required field Telephone Number Required field Mobile Email Address Required field EMERGENCY CONTACT INFORMATION Emergency Contact Last Name Required field Emergency Contact First Name Required field Emergency Contact Middle Initial Emergency Contact Address Required field City Required field State Required field ZIP Required field Emergency Contact Telephone Number Required field Emergency Contact Mobile Required field Relationship Required field Email Address Required field INTAKE QUESTIONS Date of Birth Required field Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Age Required field Gender Required field Male Female Ethnicity Required field Hispanic / Latino Other Race Required field American Indian / Alaskan Native Asian Black or African American White Native Hawaiian / Pacific Islander Two or more races Unknown Marital Status Required field Single Married Divorced Widower Unknown Housing Status Required field Assisted Living Dependent – Family/Friends Homeless Independent Institution Other Rent – Subsidized Rent-Unsubsidized Employment Status Required field Unemployed Sheltered Supported Transitional Internship Part-time Full-time Retired Unemployed – Seeking Employment Education Level Required field Below 8th grade 9th-11th grade High School Diploma Trade Vocational Special Education Some College Bachelor’s Degree Some Graduate Master’s Degree Doctorate Other Not Applicable Contact Method Required field Standard Large Print Braille Audio TTY Email – Standard Email – Large Print Registered Voter Required field Yes No n/a Income Level Required field 0 - 5000 5001 - 1000 10001 – 20000 20001 - 30000 30001 – 40000 400001 – 50000 50001 – 60000 over 60000 Income Source Required field Child Support Employed Investment Income Railroad Pension Rental Income Retirement Pension SSI / SSDI Payments Social Security Veteran’s Pensions Others (pls. indicate) Other Income Source Are you or any of your immediate family a veteran? Required field Yes No Who the veteran is? Referral Source Required field Self ADSD VR Others (Pls. Specify) Other Referral Source Are you currently receiving Required field Medicaid Medicare Veteran's Benefits Private Insurance SERVICES REQUESTED SERVICES REQUESTED Required field Advocacy / Legal Services Assistive Technology Children's Services Communication Services Counseling and Related Services Family Caregiver Service Family Services Housing, Home Modifications & Shelter Services IL Skills Training and Life Skills Training Information and Referral Services Mobility Training Peer Counseling Services Personal Assistance Services Physical Restoration Services Preventive Services Prostheses, Orthotics, and Other Appliances Protective Services Recreational Services Rehabilitation Technology Services Sexuality Therapeutic Treatment Transportation Vehicle Modification Vocational Services Youth / Transition Services Other CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What does the cow say? Required field Fill in the blank.