Information & Resources Inquiry

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Information & Resources Inquiry

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9Questions

1
Name
First Name
Last Name
2
Phone Number
Please enter a valid phone number.
3
Email
example@example.com
4
Reason for Contacting Reaching Maximum Independence
New Diagnosis
New To The Area
Individual is facing transition
Other
5
Do you or the individual receive Medicaid or Medicaid Services?
YESNO
6
If no, are you or the individual on the waiting list?
YESNO
7
Relationship to Individual with IDD
Self
Sibling, Grandparent, other family member
Parent
Legal Guardian
Professional Teacher
Other
Other
8
We need information on...
Education / School System
Leisure and Recreation
Financial Planning
Guardianship
Housing (Group / Foster)
Transportation
Legal Information
Support Groups
Supported Employment / Job Readiness Services
Medicaid / Medicare
I want to choose RMI as my provider
9
Tell Us How Else We Might Help You?
Should be Empty:

Question Label

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