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The Arc of the Triangle Information and Resources Questionnaire
The Arc of the Triangle wants to assist you in finding support and answers. Please fill out the following questions and we will do our best to get back to you within 3 business days.
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* Indicates required question
Reason For Contacting The Arc of the Triangle
*
New diagnosis
Moving to North Carolina for another state/country
Individual is facing transitions
Other:
Required
Name of Person Contacting The Arc
*
Your answer
Relationship to Individual
*
Self
Parent
Sibling
Professional
Legal Guardian
Teacher
Other:
Contact Information - Email
*
Your answer
Contact Information - Phone
*
Your answer
Contact Information - Mailing Address
Your answer
Contacting on Behalf of (Individual's Name or Initials)
Your answer
Individual's Diagnosis(es) (check all that apply)
*
Intellectual/Developmental Disabilities
Down Syndrome
Autism Spectrum
Cerebral Palsy
Traumatic Brain Injury
Visual Impairment
Hearing Impairment
Mental Health
Substance Abuse
Other:
Required
Gender
Male
Female
Clear selection
Date of Birth
*
MM
/
DD
/
YYYY
Is the individual currently receiving Medicaid?
*
Yes
No
If yes, from what county, state
Your answer
We need information on (check all that apply)
*
Services (Innovations, Medicaid, Personal Care, Respite, Community Based Services)
Employment Services
Education/School System
Leisure and Recreational
Special Needs Financial Planning
Legal Information
Crisis Services
Housing
Transportation
Other:
Required
What else would you like us to know?
Your answer
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