Balance Mi-Skills Information Form
To find out more about our services, please fill out an information form. We will get back to you with in 5 business days.
* Required
Your first and last name
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Your answer
Name of individual to receive services
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Your answer
Home/mailing address of person receiving services (street address, city, state, zip code)
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Your answer
E-Mail address
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Your answer
Phone number to best reach you
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Your answer
How to best reach you:
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Email
Phone
Time to best reach you (i.e. weekdays between 1-4 p.m.)
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Your answer
Age of person who would receive services (i.e. 16 years)
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Your answer
Select an option below
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I am 18 years or older and my own guardian
I am the parent or guardian of someone who may benefit from services
I am a therapist, teacher, or other professional interested in learning more
I am a counselor at Michigan Rehabilitation Services(MRS) / Bureau of Services for Blind Persons (BSBP)
Other:
If you represent MRS/BSBP, please provide the office location (e.g. county, city)
Your answer
If individual is still in high school, please provide the name of the high school
Your answer
Grade of individual if in high school:
9th Grade
10th Grade
11th Grade
12th Grade
Other
Post-High School Program (at district building or intermediate school district program for 18-26 year olds)
Clear selection
Pertaining to the individual's time in high school, please specify:
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Individual is/was MAINLY (over 50% of the time) in general education (may have a resource hour for additional support)
Individual is/was MAINLY (over 50% of the time) in a contained classroom (e.g. EI, CI, ASD)
Other:
Pertaining to the individual's finishing high school, please specify:
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Individual will/did receive or did receive a state diploma
Individual will/did receive or did receive a certificate of completion
Other:
Interested in:
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Teen Communications, Social, and/or Employment Social Skills Groups
Adult Communications and Soft Skills for Employment Workshops
Individual Services (teen or adult)
Employment Preparation Training
Adaptive Skills (safety, sexual health, self-advocacy, other)
Other:
Required
Provide any additional information which may be helpful
Your answer
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