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Please check the appropriate responses for the services described below.
ASSISTIVE TECHNOLOGY: Services/Devices/Home or Workplace Modification; Wheelchairs, hearing aids, talkers, switches, signalers. TTY's interpreters, Braille materials, computers and programs, scooter, walkers, ramps, etc.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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CASE MANAGEMENT: A person or agency to help you access and coordinate all available services.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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COUNSELING: Professional help with vocational and personal problems and/or with developing coping skills.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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EDUCATION: Children under 22 with disabilities receive appropriate education and reasonable accommodations, transition services to work or higher education.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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EMPLOYMENT: Job search and placement, job preparation, on-the-job training, work site adaptations, job coach.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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FAMILY SUPPORT SERVICES/RESPITE SERVICES: Assistance to family members; support groups.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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HOUSING: Affordable, accessible, or group home
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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INDEPENDENT LIVING: Training and services to allow maximum self-sufficiency, advocacy, peer counseling, and community education.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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MEDICAL/THERAPEUTIC ASSISTANCE: Medical services, dental services, physical or occupational therapy, medical insurance.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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PERSONAL ASSISTANCE: Activities of daily living: bathing, communicating, cooking, dressing, eating, housekeeping, shopping, toileting.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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TRAINING: From qualified service providers such as: Interpreters, inhome caregivers, medical practitioners.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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TRANSPORTATION: Available and accessible public or private transportation.
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| Service is available and (check one):
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Okay [ ]
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Not Okay [ ]
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| Service is needed but (check one):
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Unavailable [ ]
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Too Costly [ ]
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Comment: ________________________________________________________________________
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OTHER COMMENTS:
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