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Governor's Council on Disability
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Provider Update
Provider information
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1. Demographic Information
Organization Name:
*
Address:
*
Address 2:
City:
*
State:
Alabama
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Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
*
Zip:
*
Email:
*
Phone Number:
*
Toll Free Number:
TTY/TDD Number:
Web Address:
2. Ages Served:
*
Ages 0 - 18
Ages 18 and up
3. Please check the services that are provided by your agency:
*
Advocacy Services
Adaptive Medical equipment (i.e. prosthetics, wheelchairs, etc)
Assistive Technology (i.e. assistive listening devices, communication devices, etc)
Behavioral therapies
Case Management Services
Emergency Preparedness
Employment Resources
Educational Resources
Healthcare
Housing assistance
Independent living Skills training
Legal Services
Parent Supports
Peer Supports
Personal Attendant Care Services
Psychological testing or assessment
Recreational Activities
Rehabilitation Services (PT, OT, Speech Therapy)
Respite Care
Service Animals
Specific Disabilities (i.e. , Deafness, Developmental disabilities, etc)
Transportation resources
4. Please check all disabilities/conditions your agency serves:
*
Autism Spectrum Disorders
Deafness/Hard of hearing
Developmental disabilities
Health related conditions
Learning disabilities
Neurological disabilities
Orthopedic conditions
Psychiatric disabilities
Respiratory Conditions
Neuromuscular conditions
Visual impairment /blindness
5. Regions Served:
*
Central
East
Kansas City
Northeast
Northwest
Southeast
Southwest
St. Louis
6. Counties Served(Check all that apply - if all simply check "ALL"):
*
ALL
Chariton
Camden
St. Charles
Texas
New Madrid
Caldwell
Dunklin
Mississippi
Clay
Stone
Stoddard
Benton
Nodaway
Douglas
Warren
Ralls
Mercer
Livingston
Holt
Lincoln
Boone
Atchison
Randolph
Cooper
Knox
Cass
St. Louis
Adair
Shelby
Jefferson
Scotland
Daviess
Gasconade
Jasper
Lafayette
Audrain
Clinton
Washington
Jackson
Andrew
DeKalb
Pike
Osage
Putnam
Carroll
Pettis
Gentry
Bates
Montgomery
Marion
Morgan
Miller
Macon
Platte
St. Louis City
St. Clair
Saline
Cole
Franklin
Lewis
Sullivan
Maries
Monroe
Buchanan
Harrison
Pemiscot
Callaway
Worth
Schuyler
Johnson
Linn
Grundy
Howard
Clark
Iron
Ray
Henry
Moniteau
Crawford
St. Francois
Laclede
Wayne
Taney
Lawrence
Barton
Scott
Christian
Phelps
Pulaski
Carter
Ozark
Webster
Butler
Dallas
Madison
Ste. Genevieve
Barry
Reynolds
Shannon
Dent
Perry
McDonald
Hickory
Oregon
Dade
Cape Girardeau
Howell
Polk
Greene
Cedar
Ripley
Newton
Wright
Vernon
Bollinger
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