IL Service Agreement

Southern Nevada Center For Independent Living
Service Agreement

Your Name (required)

Your Email (required)

Part 1: Eligibility information (Consumer)

The grants that fund our Independent Living Services may only be for individuals with a significant disability. A staff member must determine your eligibility for service, partly from how you answer the following questions.

Please List your disabilities:

Please check wether your disability or disabilities substantially limit(s) your ability:

To Function Independently in the:
Home orCommunity orTo: Obtain EmploymentAdvance in Employment

Part 2: Requested Service Information - Please initial the appropriate box below

❖ I understand that, at any time, I may request communications in alternate formats when needed for effective communication. Please communicate with me using:

BrailleLarge PrintAudio TapeComputer Disk (Specify Format)Sign LanguageTTY

Other Language

Other

❖ I understand that, at any time, I may request that you change the way you do things when needed, because of my disability, to grant me equal access to programs and services (a "reasonable accommodation"). Please provide me with the following accommodation(s):

NoneAssistance Filling Out FormsAlternate Service Location

Other Accommodations

❖ I understand that I have to have a written Independent Living Plan (ILP) showing my goals and the steps needed to achieve them. I also understand that I can choose not to complete a written plan and can receive the same services without a written plan,:

I want to develop a written ILP for you to sign.I do not want an ILP now but I will contact SNCIL if I change my mind.

❖ I have received information about:
Independent Living Services provided by SNCILHow to appeal decisions made by SNCIL staff, including information about the Client Assistance Program (CAP)Confidentiality

❖ Satisfaction Survey given and discussed for services and goals.
Signature (Please sign below)

Signature of Parent or Guardian(Please sign below)

Staff Signature:____________________________________ Date: _______________

Independent Living Plans: an Introduction