Consumer Intake Form



Southern Nevada Center For Independent Living
Consumer Intake


FemaleMale


a) Whiteb) Blackc) Hispanicd) Asiane) American Indian/alaskanf) Other


YesNo



a) Institutionb) Dependent w/family & friendsc) Assisted Livingd) Independente) Homelessf) Other


a) Full Timeb) Part Timec) Retiredd) Shelterede) Lookingf) None


a) Grade School/Lessb) Some Jr./Sr. High Schoolc) High School Graduated) Vocational/Tradee) Some Collegef) College Graduateg) Post Graduate Studyh) Now In Schooli) None of the Above


a) Drives Own Vehicleb) Uses Driverc) Arranges Transportationd) Public Transportatione) No Transportation


a) Singleb) Marriedc) Divorcedd) Widowedc) Separatedd) Othere) #Minor Children


SSDIVAOther TypeSSIPrivateInc. LevelFood StampsOtherTotal


a) Medicareb) Medicaidc) Privated) Other

2950 S. Rainbow Blvd
Suite 220
Las Vegas, Nevada 89146

Voice/TDD/TTY: (702) 889-4216
Nevada Relay 711
Toll Free: (800) 870-7003
Fax: (702) 889-4574

Email: sncil@sncil.org