Date: ____ Consumer Information

Last Name: First Name: ______________________________________

Address City: _____

Mailing Address_________________________________________________________________________

State____ County: ___________ Zip: ______ Phone #_____-_____-______ Voice  TTY 

Marital Status:_______Number in Household:_______Head of Household:_______

DOB____/____/____ Age: ____ Gender: M  F Language:____________________________________

E-mail:____________________ Referred By: ____________________

rimary Disability Secondary Disability Ethnicity

 Cognitive  Cognitive  White
 Physical  Physical  Black/African-Amer
 Hearing  Hearing  Hispanic
 Multiple Disability  Multiple Disability  Asian/Pac-Islander
 Mental/Emotional  Mental/Emotional  Native American
 Vision  Vision  Unknown
 Other:__________  Other:__________  Other:__________

Living Arrangements Source of Income

 Independent – Self  Social Security Disability  Employment

 Dependent/Family or Friend  Supplemental Security Inc  Veterans
 Homeless  Social Security Retirement  Workers Comp
 Assisted Living  Pension  Other:
 Other:_______________  Unemployment  None
 Institution (Please select one Emergency Contact
of the following) Name:___________________________________________
 Acute Medical Address:_________________________________________
Phone:__________________________________________
 Sub-Acute Medical
 Skilled Nursing Are you a Dept. of Rehabilitation Client?  Yes  No
Are you on IHSS?  Yes  No
Mode of Transportation
Do you live in Subsidized Housing?  Yes  No
(Please check all that apply)
PIRS Checklist Only
 Own  Taxi  Bus  Bike
 Describe Services  CAP/Grievance Consumer Rights
 Para-Transit  Family/Friends ILP: Developed ___/___/___ Waived ___/___/___
 Other:__________ Voter Registration ___/___/___ 3-14 A