CILSWKS Logo

Center for Independent Living Southwest Kansas

Pictures of Consumers
"To Advocate for Opportunities, Independence, and Civil Rights of People with Disabilities"
.: Resources :.
PCA Information Personal Care Attendant Information and Resources Revolutions June 2008 Newsletter SW Kansas Legislature Southwest Kansas Legislature
.: Staff Resources :.
Staff Login Staff Login Web Mail Staff Webmail
.: Subscribe :.

Contact Information
Last Name:
First Name: Middle Initial:
Address 1:
Address 2:
City: State: Zip Code:
County:
Phone 1:
Phone 2:
Demographic Information
Date of Birth:
Gender: Male Female
Marital Status:

Ethnicity:
(check all that apply)

White African American
Hispanic American Indian / Alaskan
Asian Other
Unknown  
Education Level:
Disability Information
Social Security Number:
Medicare Number:
Medicaid Number:
Onset of Disability:
Primary Disability:
Secondary Disability:
Living Situation:
Living Arrangements
Accessible:
Yes No
Mode of Transportation:
Employment / Financial Information
Employment Status:
Income Level:
Funding Source:
Were you refered to
CILSWKS by Voc. Rehab?
Yes No
Medical Information
Doctor's Name:
Doctor's Address:
Doctor's City, State:
Services Requested (check all that apply)
Information and Referral Peer Support
Counseling Service Coordination
Advocacy / Legal Services Housing Assistance
Accessibility Consultation Employment Assistance
Community Integration Transportation
Interpreter Services Advocacy / Benefits
Support Groups Career Planning
Youth Services IL Skills Training
Recreational Services Communications Services
Personal Assistance Services Services to Family Members
Prostheses / Appliances Assistive Devices / Equipment