Clone of BB: Program Interest

1

Please read before proceeding

Breaking Barriers can only serve:

California Residents
Regional Center (RC) clients
Self Determination Program (SDP) clients through their RC
Private pay clients

Important: Breaking Barriers does not offer housing support or reentry services.

2

Are you looking for housing or reentry services?* This field is required.

YESNO

3

Select your State* This field is required.

4

Are you located in Los Angeles County?* This field is required.

YESNO

5

What city are you located in?* This field is required.

6

Are you 18 or older?* This field is required.

YESNO

7

Do you have a diagnosed developmental disability?

YESNO

8

Are you registered with your local regional center?* This field is required.

YESNO

9

Are you looking for job/social/educational support or all of the above?* This field is required.

YESNO

10

Are there any behaviors you would like to work on?* This field is required.

YESNO

11

What is your name?* This field is required.

First Name

Last Name

12

What is your age?* This field is required.

13

E-mail* This field is required.

example@example.com

14

Phone Number* This field is required.

Area Code

Phone Number

17

What is your preferred method of contact?* This field is required.

Phone Call

Text Message

Email

18

Comment or Message* This field is required.