IRR Eligibility Form

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IRR Intake Form

Email *

Name *

Address *

City *

State *

Alabama

Zip code

County

Phone Number *

Date of Birth *

YYYY

Age

Gender

Male

Female

Prefer not to say

Other:

Clear selection

Race *

Black or African American

White

Native American/ American Indian

Native Hawaiian other Pacific Islander

Asian

Other:

Required

Ethnicity *

Hispanic or Latino

Other

Disability (optional)

How did you hear about us? *

Housing Status *

Employment Status *

Income Sources *

Employment

Social Security Disability

Supplemental Security Income

More than one of the above

Other:

Required

What services are you in need of?

Advocacy

Independent Living Skills Training

Information and Refferals

Peer Support

Transportation

Other:

Were you negatively affected by the COVID-19 pandemic? *

Yes

If you have been negatively affected by the COVID-19 pandemic, give a brief description.

Submit

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