IL Service Agreement

Southern Nevada Center For Independent Living

    Southern Nevada Center For Independent Living
    Service Agreement

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

    Home orCommunity orTo: Obtain EmploymentAdvance in Employment

    BrailleLarge PrintAudio TapeComputer Disk (Specify Format)Sign LanguageTTY

    ❖ 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 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.

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

    Staff Signature:____________________________________ Date: _______________

    Independent Living Plans: an Introduction

    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