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How old is this person?
20 to 30 years old
31 to 40 years old
41 to 50 years old
51 to 60 years old
61 to 70 years old
Over 71 years old
What types of challenges do they face?
Physical (pain, mobility, functional)
Challenges related to limb loss
Emotional & Behavioral
Cognitive
Challenges completing daily tasks
Speech-related
Vision-related
Other (please specify)
What other types of challenges are they facing?
Where are they located?
City
State
State
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American Samoa
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District of Columbia
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Have they ever been diagnosed with a condition or disability?
Yes
No
To the best of your knowledge, what was the event that caused the condition/disability?
Acute/traumatic injury
Illness
Congenital condition
I’m not sure
What are some goals they hope to achieve through care?
Improve behaviors & stresses
Improve speech abilities
Treat pain/functional limitations
Live independently/reduce the need for a caregiver
Work or return to work
Be able to drive
Achieve educational goals
Become more involved in the community
Engage in new/old hobbies
Other
Do they have a reliable and consistent means of transportation?
Yes
No, I would need assistance
I’m not sure
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