Name
*
First Name
Last Name
Relationship to Individual with IDD or autism (check all that apply)
*
Self
Parent
Sibling, Grandparent, other family member
Legal Guaridan
Professional/Teacher
Other
(if applicable) Contacting on behalf of [name or initials are fine]
Individial Diagnosis(es) [check all that apply]
*
Intellectual/Developmental Disabilities
Autism Spectrum Disorder
Down Syndrome
Cerebral Palsy
Traumatic Brain Injury
Hearing Impairment
Visual Impairment
Behavioral Health Diagnosis
Other Diagnosis
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Contacting Triangle Disability &Autism Services (check all that apply)
*
New diagnosis
New to the area
Individual is facing transitions
Other reason
Does the individual receive Medicaid or Medicaid Services?
Yes
No
If "yes", what county/state provides the Medicaid?
If you answered "no", are you on the Waiting List (Registry of Unmet Needs)?
No, by choice
No, I do not know what that is
No, I have been told we do not qualify
Yes
We need information on:
*
Choosing TDAS as my Medicaid Service Provider or Supported Employment Provider
Education/School System
Leisure and Recreation
Special Needs Future & Financial Planning
Guardianship
Housing
Transportation
Legal Information (we do not dispence legal advice but will try to get you the resources you need)
Transition to Adulthood
Support Groups
Tell us how else we might help:
Submit
Information & Resources Inquiry
Should be Empty: