"Empowering people with disabilities to live independently in our community."

PERSONAL ASSISTANT REQUEST FORM

To request a Personal Assistant, please fill out and submit this form. Our Personal Assistant Coordinator will contact you to discuss your options.

Name
Address
City, State and Zip
County
Telephone (home)
Telephone (work)
Telephone (cell)
Gender
Are you a DRS/HS customer?
According to your service plan, is a CNA required for any special services?
If so, what services are required?
Personal Assistant Needs
Do you require assistance with transfer lifting?
Do you smoke?
Can your personal assistant smoke?
Do you have pets in your home?
Is a live-in personal assistant required?
Does the personal assistant need to have a car?
Is this request for an emergency backup personal assistant?
Do you need additional training in working with a personal assistant?
Do you prefer a male or female personal assistant?
What days of the week do you need a personal assistant?
Are there specific times when you need a personal assistant?
Morning Afternoon Evening Night
Other important information you would like to share:

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