Name: Age: Address: City:    State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NB NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  Zip: County: Phone: Email:     Supports & Services Needed: Advocacy Adult Day Services Assitive Technology Childcare Educational Infant/Toddler Program Info & Referral Behavioral Services Respite Legal Services In-Home Services Related Services (OT/PT/Speech) Outreach & Support Vocational Services Service Coordination Residential Service Recreational/Social Activities Transportation Financial Management Connection Services Self Determination Transition     Services Not Listed Above:     Other Information You Are Seeking:     Disabilities: (hold the Ctrl key to select multiple Disabilities) ADD/ADHD Developmental Delay Down Syndrome Visually Impaired Orthopedic Injury Autism Neurologically Impaired Traumatic Brain Injury Emotional/Behavioral Learning Disability Multiple Disabilities Health Impaired Mental Retardation Suspected (undiagnosed) Hearing Impaired Speech/Language Disorder Other       © 2002 Council for Mental Retardation. 1146 South Third Street. Louisville KY 40203-2997. All rights reserved. To contact, call 502-584-1239. Site created by Xpressions Interactive Inc.