Form Dhs 1277 - Service Questionnaire Page 6
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10Special programs
(check all that you are involved with)
Adult Education and Literacy Programs
Intellectual and Developmental
Disabilities Agency
Adult Parole/Probation
Juvenile Parole/Probation
Alcohol and Drug
Latino Connection-Easter Seals
Alcohol and Drug — Youth
Medical Health Provider (public or private)
American Indian VR Services Program
Mental Health Provider (public or private)
Career Workforce Skills Training
One-Stop Employment/Training Center
Center for Independent Living
Other State Agency
Child Protective Services
Other VR State Agency
Community Rehabilitation Program
Public Housing Authority
Consumer Organization or Advocacy Group
School — not Youth Transition Program (YTP)
DD Brokerage
Schools Youth Transition Program
DD County Case Management
Seasonal Farm Workers (SFW)
DOL Employment and Training
Service Programs
SSA (Disability Determination Service or
district office)
Educational Institution
(elementary/secondary)
State Department of Correction/
Juvenile Justice
Educational Institution (post-secondary)
State Employment Service Agency
Employed Persons with Disability
Supported Employment
Employer
Temp Assistance to Needy Families (TANF)
Employment Network (not otherwise listed)
Veterans Administration
Employment Transition Services
Welfare Agency (state or local government)
Experience Works
Work Readiness Workshops
Federal Student Aid (pell grant, SEOG,
work study, etc.)
Workers’ Compensation
General assistance
Workers’ Compensation (special fund)
Independent Living Services
None
Please list any and all other agencies and organizations that you are currently involved with
(Self-Sufficiency, Adults and People with Disabilities, Mental Health, etc.):
Name of agency:
Contact person:
Phone number:
Page 6 of 10
DHS 1277 (10/2016)
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Parent category: Legal