Alliance of Disability Advocates

ADANC Intake Form

ADANC’s Information and Referral Services Manager may be calling you to find out more information about your situation. Due to a disability, the staff member may be calling you with an operator using a system called Relay.

Please be patient with our staff and understand that we are doing our best to connect you with the requested services.

Contact Information

Name

First Name

Last Name

Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone/TTY/TDD/VRS

What is your preferred contact method?

Phone

Text

Preferred method of working with an Alliance staff member

In-person

Remotely (by phone or videoconferencing)

No Preference

Demographics

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Non-binary

Other

Prefer not to Say

Are You A Veteran?

Yes

Race/Ethnicity

American Indian/Alaska Native

Black/African American

White

Two or more races

Asian

Native Hawaiian/Pacific Island

Hispanic/Latino

Race Unknown

Received Benefits and Services Requested

Services Requested

Please select the service you need assistance with.

Information and Referral

Advocacy

Peer Support

Independent Living Skills Training

Transition Services

Employment

Housing

Youth Transition

Benefits Counseling

Information and Referral

What kind of resources are you looking for?

Advocacy

What issue would you like a Community Inclusion Specialist to assist you to advocate for?

Peer Support

What kind of support would you like from our Community Inclusion Specialist?

Independent Living Skills Training

What independent living skills would you like to work on with one of our Community Inclusion Specialists?

Some examples can include budgeting money, cooking, and household management skills.

Transition Services

What kind of transition would you like support with?

Employment

What kind of employment opportunity are you looking for?

Housing

Are you homeless?

Yes

Please call the resource below for the county you live in if you are experiencing homelessness. If you don’t see the county you live in listed, please call NC211 at 888-892-1162 to find an appropriate resource in your area.

Entry Point Durham - 984-287-8313

The House Wake Access Hub - 919-443-0096

The Orange County Housing Helpline - 919-245-2655

The Smithfield Rescue Mission - 919-934-9257

What is your monthly income?

The purpose of this question is to determine eligibility for the Targeted Unit Housing Program.

What type of housing are you looking for?

Youth Transition

Are you still in high school or have you already graduated?

Still in High-School

Graduated

What kind of support are you looking for?

Benefits Counseling

What is Benefits Counseling?

Do you already receive disability benefits?

Yes

Do you want to start working or go back to work?

Yes