Adult Support Interest Form

Select the role that best describes you(Required)

Parent or Guardian Name

First Last

Relationship to person

Parent or Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent or Guardian Email

Parent or Guardian Phone

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

Select the County you live in(Required)

Please share your ethnicity(Required)

What is the preferred language in your home?

Are you your own guardian?(Required)

What is your diagnosis?(Required)

What year did you receive your diagnosis?(Required)

Are you enrolled in school?(Required)

Do you currently receive any services from the state of North Carolina?(Required)

Describe the services you receive

I need help with (check all that apply):(Required)

Finding a job

Keeping my job

Counseling services

Becoming more independent in my home life

Becoming more independent in my community

Accessing services like Medicaid (a 1-on-1 worker)

Social activities, groups, and/or meet ups

Other

Please describe how we can help you

Would you like to be added to our email list?(Required)