Address:     [apt. #]:

Street:

Mailing Address:

City:     State:     Zip Code:

Home Phone Number: ()-

Work Phone Number: ()-

Disability::

Date/How Long:

Age:

Married/Single:     # of Years Married:

Children:   Age:

Native Language:    

Languages spoken other than English:

Occupation:

Educational Background: (including highest grade completed:)

Specific interests/hobbies:

Sports:

Member of any organizations:


Issues you feel comfortable discussing:

Vocational	Educational	Sexuality Issues
Caregiver Issues	Sports/Recreation	Relationship Issues
Money Issues	Drug & Alcohol	Suicide/Depression
ADL/Activities of Daily Living	Anger

(Those skills required for everyday functioning, such as transferring from bed to wheelchair, dressing, eating, getting in and out of a car or other skills for daily functioning relating to a Disability)

Are there any issues you do NOT feel comfortable discussing? (If so, please describe):


What Disabilities make you uncomfortable?:

None

Other

Multiple Disabilities

TBI

Speech Impediment

Times Available:

Days:  
Times: