This form is available in English and Spanish. Click on the top right and choose your language of preference. 

Este formulario está disponible en Inglés y Español. Haga clic en la parte superior derecha y elija el idioma de su preferencia.

This online ADULT intake is for the individual who identifies as having a disability and is seeking services for themselves.

This Intake should not be completed by anyone else without the individual present, and it must not be signed by anyone but the individual.

Without a proper signature, the intake can not be accepted.

As the Consumer, you will be completing 4-5 Intake forms to receive free services from Taconic Resources for Independence, Inc. (TRI)

You must answer each question with a " * ".

As you complete each form, there will be a button labeled "NEXT" at the bottom right of the page. Click on it to proceed to the next form.

To go back to review any form click on the gray button labeled "BACK" on the bottom left of the last page of the form you are working on. 

Some information will be automatically filled in based on your initial responses. Once you have completed all the forms you must click on the green button labeled,

"Click Here to Submit the Completed Intake Packet of Forms" 

You will then see a Thank You page, confirming your submission. 

 Your forms will be securely sent to TRI staff. Someone will contact you within a few business days.  If you do not hear from anyone, feel free to contact the office.

You will have the option to "Download PDF", for your own records. This is just a copy. Do NOT mail or email us this pdf form.

If you are having trouble completing these forms online, stop. Call the front desk: (845) 452-3913 ext.0 between regular business hours 9am-5pm to request for the Intake Packet to be mailed to you. If you are leaving a voice message, spell your full name, mailing address, and provide your phone number.

CONSUMER INTAKE FORM

Please check ALL disabilities that apply to you. At least one disability category MUST be checked off to receive services.

PLEASE READ AND SIGN:

I have been informed of my right to confidentiality regarding any services I received from Taconic Resources for Independence, Inc. This includes the right to have my name and/or my personal information not released to any other source without my consent. I have been informed of the Independent Living Services available, my right to request more or different services, my right to appeal the services/treatment provided to me through the Client Assistance Program at (800) 993-8982. You can also speak with a TRI supervisor. You may also contact Joseph Tedesco, NYS Education Department Phone# 518 408-4850, Joseph.Tedesco@nysed.gov , ACCES-VR/Service Delivery, 89 Washington Avenue, 5th Floor, Room 580 EBA, Albany, NY 12234. 

By signing this form, you authorize Taconic Resources for Independence, Inc. (TRI) to allow the review of your consumer file and protected health information by the New York State Education Department's Office of Adult Career and Continuing Education Services ("ACCES," formerly VESID).

As an  Independent Living Center, TRI receives funding from NYSED ACCES. NYSED ACCES has the obligation to monitor that our services meet certain eligibility criteria and standards pursuant to state and Federal law. The information reviewed will only be used for the purposes, set forth below [continued on 2nd page], and will only be used and shared by authorized ACCES

You have a right to decline this authorization. Your services, the payment for your services, and your health care benefits will not be affected if you choose to decline. If you sign this form, you will have the right to revoke it at any time, except to the extent that the Independent Living program has already taken action based upon your authorization. To revoke this authorization, please write to the Program Manager of the Independent Living program in which you participate.

USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. A representative of TRI must answer these questions completely before providing this authorization form to you. DO NOT SIGN A BLANK FORM.

To submit my file for REVIEW ONLY by the agency, individual, or employer identified below:

Name/Title or Organization: NYSED ACCES

Address: 89 Washington Avenue, EBA 5th Albany, N.Y. 12234 (518) 474-2925

Fax:518-473-6073

What information will be reviewed?

Entire contents within your file for the purpose of monitoring, by NYSED ACCES, of TRI's compliance with the with the (Centers for Independent Living) Standards, including the following: Date of Birth; Gender; Race/Ethnicity (if provided); Employment and Education status; County where you reside; Veteran status and Disability information. Required documents, such as Consumer Rights and Responsibilities, Consumer Grievance, Individual Authorizations (Consents) and Documentation of Services will also be reviewed.

* Please note: Information within your file will only be reviewed and no contents of your file shall be removed, nor will any copies be made for this NYSED ACCES review.

What is the purpose of this review?

Monitoring, by NYSED ACCES, of TRI's compliance with the eligibility requirements for ILCs and compliance with the CIL (Centers for Independent Living) Standards as identified above.

When will this authorization expire?

This authorization shall remain in effect for one year beyond the date it is signed unless you revoke it in writing.

Signature

I have read this form and all of my questions about this form have been answered.

Mission Statement

Taconic Resources for Independence, Inc. advocate for the civil rights of individuals with disabilities in Dutchess County and empower them to lead self-directed lives with independence and dignity.

TRI’s Vision Statement

We believe in a society where individuals with disabilities are able to experience full inclusion to participate in all aspects of community life and have equal access to the same opportunities and freedom as the general public.

TRI provides services to you with no charge. In order to obtain outside funding, however, we need to keep records on those we serve. We ask that you take a few minutes to read this information sheet and complete the intake form.

1. Independent Living Philosophy – At Taconic Resources for Independence, Inc. you are neither a “patient” nor a “client”, but a “consumer” of services. YOU determine the services you want, YOU decide what is best for you, YOU are in control. TRI’s staff will provide you with any information and referral so that YOU can make choices about your living arrangements, transportation, employment, etc. We are committed to your efforts to achieve greater independence in the community.

2. A Consumer Service Record (CSR) Form - This is the information our funding sources ask us to collect on all of our consumers.

3. CONFIDENTIALITY - It is our policy to protect your rights as a consumer seeking services by maintaining confidentiality regarding any of your personal information, records kept, and services provided. Center staff will refrain from discussing your issues with anyone who is not a TRI staff member or releasing your information that may be requested by third parties, without your written permission.

4. The Consent to Release/Receive Information Form - This form authorizes us to request/release/receive information from various facilities and agencies and/or individuals on your behalf.

5. INDEPENDENT LIVING PLAN - We are available to assist you in developing a personal plan to achieve independent living goals - goals which you feel would help you to lead a more independent life in the community. This plan will let you know what role we can play and what you may need to do in order to meet the goals. This plan is not a requirement for receiving any services at the center. This is a personal plan to help you achieve independent living goals. It is your option to develop one or not. It can act as of "road map" to help you lead a more independent life in the community.

6. A Voter Application - Please speak to your advocate if you are not registered and would like to register, or if you need any information about polling sites. If you are not registered to vote where you live now, would you like to apply to register here today?

7. CONSUMER APPEALS PROCESS - It is our sincere hope that our services are always delivered in the most professional manner. However, if the service delivery or interactions with staff are not satisfactory to you, we want you to know that you have the right to discuss the issue with representatives who have progressively higher levels of organizational responsibility. You may first ask to speak to a supervisor and then the Executive Director. The office of Adult Career and Continuing Education Services (ACCES) is also available to consider complaints by calling 518-486-3777 or by writing to Joseph Tedesco, NYS Education Department Phone# 518-408-4850, Joseph.Tedesco@nysed.gov , ACCES-VR/Service Delivery, 89 Washington Avenue, 5th Floor, Room 580 EBA, Albany, NY 12234, or sending an email Joseph.Tedesco@nysed.gov. You may also use the Client Assistance Program staff (see below).

8. CLIENT ASSISTANCE PROGRAM - The Client Assistance Program (CAP) is responsible for assisting individuals with all disabilities who are receiving or requesting rehabilitation or other services to secure the benefits and programs available under the Rehabilitation Act of 1973 as amended. You have the right to speak, at any time, with the Statewide Client Assistance Program Coordinator by calling (800) 993-8982 (Voice/TYY) or (518) 432-7861 or E-mail: mail@disabilityadvocates.org or writing to: Disability Rights New York/Disability Advocates, Inc. 725 Broadway, Suite 450 Albany, NY 12207.

We appreciate your time and effort in completing the necessary forms to the best of your ability. If you have any questions, one of the staff will be glad to answer them when they meet with you.

TRI strives to create a safe and healthy environment for people with disabilities. Again, thank you very much for trusting us to provide you with quality services.

"By signing this letter, I am confirming that I have been informed of my right to confidentiality regarding any services I received from Taconic Resources for Independence, Inc. This includes the right to have my name and/or my personal information not released to any other source without my consent. I have been informed of the Independent Living Services available, my right to request more or different services, my right to appeal the services/treatment provided to me through the Client Assistance Program; as well my right to speak with a TRI supervisor, as well contact Joseph Tedesco, from the NYS Education Department".

This is an additional form to the initial Intake Packet. A new form is to be completed for all returning consumers. If you have any questions about this form, speak with your Advocate directly, or you may ask the front desk to assist you: 845-452-3913