Actually Disabled

Hi! Thank you for reaching out to us! This questionnaire is intended to help determine if Actually Disabled is a good fit for you. It also will help me prepare for our meeting so I can come in with an idea of who you are, what goals you have, and what resources could be beneficial for you so you can get the most out of our time together as possible. All questions are optional, but the more information you can provide, the more helpful I can be!

After I review your form, I will reach out to you via the preferred method you indicate below.

*Please do NOT disclose any sensitive medical, financial, or personal information using this form. If it is later deemed necessary for us to have such information, we will provide a more secure platform.

Who is filling out this survey?
I, the person seeking services, am filling this out myselfI, the person seeking services, am filling this out with helpI, a friend or family member, am filling this out on behalf of the person seeking servicesI, a professional, am filling this out on behalf of the person seeking services

Who is seeking services?

Pronouns

Age

What is your email?

What is your phone number?

How should I contact you?
Call meText meEmail me

How long have you had your disability? What would you like me to know about your disability?

How comfortable are you talking about your disability?
1 – I'm incredibly uncomfortable talking about disability2345 – I'm neutral when it comes to talking about disability678910 – I could talk disability all day!

Do you have any past experience working with disability consulting services? If so, what was that experience like for you?

How would you describe the impact your disability has on your life?

How would you describe your current level of connection to and involvement in the disabled community? Are you hoping to find more ways to connect with other disabled folks?

What challenges do you experience that you feel are related to your disability?

What challenges are you experiencing that are not directly disability related?

What is your financial situation like?
1 – No money to spare2345678910 – Money is not a concern at all

What are you good at?

What do you like to do for fun?

What’s one thing you accomplished this week that you are proud of?

What are you hoping to get out of our meeting together? Is there anything specific you are wanting Actually Disabled to help with?

Are there any resources you have found helpful already that you want more people to know about? They don’t have to be disability related!

Will there be anyone else joining you for our meeting?

How did you find Actually Disabled? We like to know how best to reach people who could benefit from our services!

Anything else you want me to know?