Alliance of Disability Advocates · 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 at (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

Name

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

*

Phone

*

Email

Verify Email

Preferred Contact Method

*

Phone

Text

Email

Who is this referral being made by?

*

Please select the role of the person completing the referral form.

Agency

Self

Individual not affiliated with an agency on behalf of consumer (friend, family, etc.)

Is this a TCL Referral?

*

Please select "Yes" if the person you are referring is part of the TCLI program.

Yes

No

Do you work for an LME/MCO?

*

Please select "Yes" if you work for an LME/MCO and "No" if you work for another type of organization.

Yes

No

Error: TCL Referrals from LME/MCOs only

Referrals for TCL services though the Center for Independent Living must come from an LME/MCO. Please contact the LME/MCO that the consumer works with about making the referral.

Which LME/MCO do you work for?

*

Please select your Organization

TCL Alliance Health

TCL Eastpointe

TCL Sandhills

TCL Partners

Does this consumer have an ACT team?

*

Yes

No

Services Needed

*

Independent Living Skills Training

Advocacy Training

Peer Support

Suit Closet

Transition Services

Housing Services

Youth Transition Services

Benefits Counseling

Other Information

How did you hear about us?

*

Another Agency

ADA Website

Social Media

Word of Mouth

Other

Name of Agency

*

Contact Person at Agency

If you have the name or contact information of the person who referred you, please include that here.

Please state the "other" place you heard about us.

*

Referring Agency

Name of the Organization

*

Staff Member

*

Staff Phone

*

Staff Email

*

Verify Email

*

Referring Individual

Name of Person Completing Form

*

Name of person completing form on behalf of consumer

Relation to Consumer

*

Phone

Email

Verify Email