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.
Reason For Contacting The Arc of the Triangle *
Required
Name of Person Contacting The Arc *
Your answer
Relationship to Individual *
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) *
Required
Gender
Date of Birth *
MM
/
DD
/
YYYY
Is the individual currently receiving Medicaid? *
If yes, from what county, state
Your answer
We need information on (check all that apply) *
Required
What else would you like us to know?
Your answer
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