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