Information
About You: (privacy
statement )
1. County
of Residence?
Not in North Carolina
ALAMANCE ALEXANDER ALLEGHANY ANSON ASHE AVERY BEAUFORT BERTIE BLADEN BRUNSWICK BUNCOMBE BURKE CABARRUS CALDWELL CAMDEN CARTERET CASWELL CATAWBA CHATHAM CHEROKEE CHOWAN CLAY CLEVELAND COLUMBUS CRAVEN CUMBERLAND CURRITUCK DARE DAVIDSON DAVIE DUPLIN DURHAM EDGECOMBE FORSYTH FRANKLIN GASTON GATES GRAHAM GRANVILLE GREENE GUILFORD HALIFAX HARNETT HAYWOOD HENDERSON HERTFORD HOKE HYDE IREDELL JACKSON JOHNSTON JONES LEE LENOIR LINCOLN MACON MADISON MARTIN MCDOWELL MECKLENBURG MITCHELL MONTGOMERY MOORE NASH NEW HANOVER NORTHAMPTON ONSLOW ORANGE PAMLICO PASQUOTANK PENDER PERQUIMANS PERSON PITT POLK RANDOLPH RICHMOND ROBESON ROCKINGHAM ROWAN RUTHERFORD SAMPSON SCOTLAND STANLY STOKES SURRY SWAIN TRANSYLVANIA TYRRELL UNION VANCE WAKE WARREN WASHINGTON WATAUGA WAYNE WILKES WILSON YADKIN YANCEY
2. Category
that best describes your role in the use of this service?
I am a ... (select a description
below)
I am a consumer (person with a disability). I am a family member of a child with special needs. I am a foster parent of a child with special needs. I am a friend of a child/family with special needs. I am a professional working with families/children with special needs. I am a student doing research. Other
3. Age
group of the person needing services?
Not Applicable
PRENATAL NEW BORN - (0 TO 1 MONTH OLD) INFANT/TODDLER - (2 MO. TO 3 YEARS OLD) PRESCHOOL - (3 & 4 YEARS OLD) SCHOOL AGE - (5 THRU 8 YEARS OLD) SCHOOL AGE - ADOL. (9 THRU 21 YEARS OLD) ADULT - (OVER 21 YEARS OLD) UNKNOWN
4. Ethnic
group of the person needing services?
Not Applicable
ASIAN BLACK HISPANIC NATIVE AMERICAN OTHER WHITE
Information
About This Service:
5. Is
this your first time using this service?
Select one of the following
Yes
No
6. Do
you plan to use this service again?
Select one of the following
No
Yes
7. Were
you able to find what you were looking for?
Select one of the following
No
Yes
If
you did not find what you are looking for, type what
you were looking for in addition to your email address
and a Resource specialist will contact you. You can
also call us at 1.800.852.0042 (M-F 8am - 5pm EST) to
speak with a Resource specialist.
Email
Address
I
have received or downloaded the Notice
of Privacy Practices disclaimer
Please
list the topics you would like further information on.
Suggestions/Comments
For Improvement On This Service
Thank
you
