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Alliance of Disability Advocates Referral Form

Please fill out the following information so that we can better serve you or the person you are referring. If you have any questions, please feel free to call our office (919) 833-1117 and ask to talk to the Information & Referral Services Manager.

 

Due to the unprecedented impact of the pandemic, Alliance of Disability Advocates has received more requests for assistance than our current capacity allows. As a result, we have created a waiting list.  Please know that each request for assistance is carefully reviewed and weighted in terms of need.

 

Consumer
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Please select "Yes" if the person you are referring is part of the TCLI program.
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Referring Agency
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First Name
Last Name