Information and Referral Form         Are you already a consumer of Walton Options? Yes No Are you registered to vote? Yes No     Send voter registration information. Name:     Address: City: County: State: State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Home Phone: Other Phone: Age: Date of Birth: Month January Febuary March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Gender: Male Female         What is the nature of your inquiry? Select One General Question. (ex: "What do you do?") I would like to donate money or equipment and/or volunteer. I would like a CIL representative to come speak. I am a consumer that would like a specific service. Other How did you hear about us? Select One VR Other Agency Media IL Consumer or other word-of-mouth Internet/website Marketing Information Phone Book Other What is the subject of the inquiry?   Emergency Situation Select One Housing Eviction/Foreclosure Food Medicine Attendant No Show Domestic Violence Utility Cut Off Notice Medical Equipment Other Personal Assistance/Attendant Care Select One Respite 24 Hour Residential Support In Home Personal Care Assistance Other Financial Select One Getting Benefits/Eligibility Help with disability related expenses Help with general living expenses Transportation Select One Medically Related Non Medical Related Paratransit system complaint Other Employment/Training Select One Wants a job Needs job accomodations Wants skills training Work place discrimination Other Education Select One Wants educational opportunities Needs classroom accommodations Other Access to Information Select One People with hearing disabilities People with visual impairments Assistive Technology/Adaptive Equipment/Durable Medical Equipment Select One Vehicle Modifications Computer Augmentation/Alternative Communication Devices Equipment for people with hearing disabilities Equipment for vision disabilities Other Housing Select One Needs wheelchair accessible housing that is subsidized Needs subsidized housing that is not wheelchair accessible Needs accessible housing but can pay market rate Needs home accessibility modification Needs home repair Home buyer program Legal Select One General legal help Disability-related legal help Other Services you are requesting: Select One Accesibility Surveys Community Education Independent Living Training Skills Nursing Home Transition Orientation & Mobility Services Other Any additional comments: