Application for Services Application for Services 1 General Information2 Services3 CARES Act Questions4 Closing Questions County*(required) Note: the majority of our services are only offered to citizens or residents of certain Alabama counties. Information & Referral Services can be provided to anyone, regardless of state or county residence.Choose a CountyBibbBlountCalhounCherokeeClayCleburneColbertCullmanDekalbEtowahFayetteFranklinGreeneHaleJacksonJeffersonLamarLauderdaleLawrenceLimestoneMadisonMarionMarshallMorganPerryPickensRandolphShelbySt. ClairTalladegaTuscaloosaWalkerWinstonMy county isn't listedDisability Rights and Resources is accepting applications for some services only from individuals residing in a limited number of Alabama counties. Information and referral service is available to all, regardless of state or county residence. All services are offered to residents of these counties: Bibb, Blount, Calhoun, Cherokee, Clay, Cleburne, Colbert, Cullman, Dekalb, Etowah, Fayette, Franklin, Greene, Hale, Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Limestone, Madison, Marion, Marshall, Morgan, Perry, Pickens, Randolph, Shelby, St. Clair, Talladega, Tuscaloosa, Walker, and Winston. If you do not live in one of the counties listed above or do not live in the state of Alabama, the only services we can provide at this time are Information & Referral services. If you don't live in one of the above counties but are a resident of Alabama and you need more assistance than we can provide through our Information & Referral services, please contact Independent Rights & Resources in Montgomery by visiting www.independentrandr.org or calling 334-240-2520 or contact the Mobile Independent Living Center by calling 251-460-0301.Name of Applicant*(required) First Last Address of Applicant*(required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which county?Select all phone number(s) which you would like to provide*(required) Home Phone Number Mobile Phone Number Work Phone Number Other Phone Number Home Phone Number*(required)Mobile Phone Number*(required)Would it be okay if we contacted you via text/SMS?*(required)(standard message rates may apply)Yes, it would be okay if you contacted me via text/SMSNo, it would not be okay if you contacted me via text/SMSWork Phone Number*(required)Other Phone Number*(required)Description of Phone Number(optional)Would you prefer us video call you, as opposed to an audio-only phone call?*(required)Yes, I would prefer a video callNo, I would prefer audio-onlyWhich video software do you prefer?*(required)I prefer FaceTimeI prefer SkypeI prefer ZoomI do not have a preferenceEmail Address of Applicant(optional) Enter Email Confirm Email Birth Date*(required) Month(MM) Day(DD) Year(YYYY) Age*(required)Gender*(required)MaleFemaleGender not listedIf desired, please specify your gender(optional)Race/Ethnicity*(required)American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteHispanic/Latino of any race or Hispanic/Latino onlyTwo or more races or ethnicitiesNot Known or Prefer Not To SayDisability*(required)If you choose to add multiple disabilities, please do so on multiple lines How did you hear about us?(optional)Living Arrangement*(required)I live in Assisted LivingI am living with Family or FriendsI live independentlyI live in a nursing homeI have other living arrangements than what is listedWhere does your income come from?(optional)My income comes from employmentMy income comes from Social SecurityMy income comes from Supplemental Security Insurance (SSI)My income comes from Social Security Disability Insurance (SSDI)My incomes comes from more than one of the above.My income comes from none of the above sourcesIf desired, please specify where your income comes fromAre you paid on an hourly or annual basis*(required)I am paid on an hourly basisI am paid on an annual basisI am paid another wayHourly Pay*(required)Average Amount of Hours (per week)*(required)Average Monthly Salary (Hidden)Annual Salary*(required) Disability Rights and Resources is accepting applications for some services only from individuals residing in a limited number of Alabama counties. Information and referral service is available to all, regardless of state or county residence. All services are offered to residents of these counties: Bibb, Blount, Calhoun, Cherokee, Clay, Cleburne, Colbert, Cullman, Dekalb, Etowah, Fayette, Franklin, Greene, Hale, Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Limestone, Madison, Marion, Marshall, Morgan, Perry, Pickens, Randolph, Shelby, St. Clair, Talladega, Tuscaloosa, Walker, and Winston. If you do not live in one of the counties listed above or do not live in the state of Alabama, the only services we can provide at this time are Information & Referral services. If you don't live in one of the above counties but are a resident of Alabama and you need more assistance than we can provide through our Information & Referral services, please contact Independent Rights & Resources in Montgomery by visiting www.independentrandr.org or calling 334-240-2520 or contact the Mobile Independent Living Center by calling 251-460-0301.Are you interested in finding answers to questions about living with a disability?(optional)YesNoInformation and Referral: Find answers to your questions about living with a disability. Get information about disability rights, resources, groups or programs that may help you, a family member, or a business. This service is provided to all residents of Alabama.Learn MoreAre you interested in developing skills for independent living?(optional)YesNoIndependent Living Skills:Learn the skills you desire to have to be independent everyday and/or to live on your own .You can pick the areas on which you want to work, like budgeting, cooking, running your home, communication, transportation, relationships, or even how to speak up for yourself.Learn MoreAre you interested in learning how to advocate for yourself?(optional)YesNoAdvocacy: Learn how to advocate for yourself and have your voice heard while acting for change that offers equal opportunity for people with disabilities. We can help you contact your government officials, write letters or make phone calls ,travel to Montgomery for special events or just figure out how to stand up for your rights in your own life.Learn MoreAre you interested in building relationships with peers?(optional)YesNoPeer Support: Learn problem-solving solutions, share successes and build relationships with other individuals with disabilities who may share your needs/concerns. Learn about new topics, such as healthy living, couponing , and job skills, while making new friends and being part of a team.Learn MoreDo you need help moving from a nursing home into the community?(optional)YesNoTransition into the Community: Receive assistance relocating from an institution into your own place. Get help learning about the things you will need to be successful - such as finding housing, setting up utilities, and arranging and getting support from others.Do you need help staying in your own home so that you don’t have to go to a nursing home?(optional)YesNoNursing Home Diversion: Help prevent entering a nursing home by identifying problems that threaten your independence and solutions that work for you.Learn MoreAre you between the ages of 14-21 and need help planning for the future?(optional)YesNoYouth Transition Services: Extra help for individuals 14-21 who are in school or have just exited school. Get help understanding your disability at any age, discovering what is important to you, and how to set goals for yourself.Learn MoreDo you need help making your home more accessible?(optional)YesNoHome Modification: We help people with disabilities in Birmingham by making their homes more accessible, for example by adding a grab bar in the bathroom or a ramp at the front door. Geographic and income limits apply.Learn MoreDo you need help getting a job?(optional)YesNoEmployment Assistance: The Disability Rights & Resources Employment Network Program provides services that assist those receiving SSDI or SSDI, and between the ages of 18 and 64 to meet their employment goals while understanding how working will affect your benefits.Learn MoreWere you negatively affected by the COVID-19 pandemic?*(required)If you answer "Yes," the green "Next" button below will take you to another page where you will be asked to describe how you have been affected by COVID-19.YesNoCARES Act Funding: If your needs are not being met or are not being sufficiently met due to COVID-19, you may be eligible for financial assistance through the Part C CARES Act program. The purpose of this program is to address the needs of individuals with disabilities and help them to access or reconnect with the services and support they need to remain safely in their communities. Needs may be related to a wide range of issues, including housing, transportation, personal assistance, assistive technology, employment, medical supplies, personal protective equipment, and more. To qualify, an individual must have a significant disability, meet certain income limits, live within the agency’s service area, and have a need that has not been met or sufficiently met due to COVID-19. All CARES Act participants must become a Disability Rights & Resources consumer. Please describe in detail how the COVID-19 pandemic has affected you and how CARES ACT assistance will help.*(required) Is the individual filing out this form the applicant named on Page 1?*(required)YesNoIf we are unable to get in touch with the applicant, can we reach out to you?*(required)YesNoName of Assisting Individual(optional) First Last How would you prefer to be contacted?*(required)PhoneEmailPhone Number(s) of the Assisting Individual*(required) Email*(required) Unique IDCAPTCHACommentsThis field is for validation purposes and should be left unchanged.