Apply for Support

By submitting this application, you are agreeing to authorize SOS to use your application information for the purpose of matching you with others registered with SOS, and to provide you with updates about SOS services. A match will be made based on the information you provide. You will not be obligated to use this service. Sharing Our Strengths will not use this information in a public format that will breach your confidentiality. Although all mentors will have specialized training, they are not experts and will not offer medical, legal, educational, or personal advice.

Applicant Information Date: / MM / DD / YY First Name: Last Name: Street Address: Street Address 2: City: State:     Zip: County: Home Phone: Work Phone: Other Phone: Email: Can you accept calls at work? Yes   No Preferred times to be contacted: AM   PM How do you prefer to be contacted? Phone   Email   Mail   What is your marital status? Single   Married / Partner   Divorced   Widow/Widower   Prefer not to say   What is your ethnicity? African American Asian Native American Caucasian Hispanic Multi-ethnic Prefer not to say Other What is your relationship to the person with a disability? Mother Father Sibling Grandparent Self-Advocate Other Family Member Friend Professional Other: If other, please describe: Main language: Other language: About the Person with a Disability First Name: Last Name: Birth date: / MM / DD / YY Gender: Male   Female Primary Diagnosis: Secondary Diagnosis: Other Diagnosis: School District, if applicable: Other disabilities, special healthcare needs, or concerns: Person with disability resides: family home foster home own home or apartment ISL group home ICFMR Habilitation Center Nursing home How long: If the person with a disability resides in your household, please provide the following information: Other family members in your household with a disability Name: Birth date: Gender: Male Female Primary Diagnosis: Secondary Diagnosis: Other Diagnosis:     Name: Birth date: Gender: Male Female Primary Diagnosis: Secondary Diagnosis: Other Diagnosis: Please list the birth year(s) and gender(s) of siblings without disabilities: Birth year: Gender: Male Female Birth year: Gender: Male Female Birth year: Gender: Male Female Birth year: Gender: Male Female Birth year: Gender: Male Female Reason for request: New/change diagnosis Change in location/area Life crises Transition stage (school/aging) Service need Medical/Health Behavior Housing/living situation Transition (hab center to community) Other Match request based on: Disability Location Area of concern Hab Center Transition Other Main topic of concern: Support/advocacy Specific disability/topic info Direct services and support Education Behavior Medical Assistive technology Housing/community living Employment Recreation Legal Other: How did you hear about us? Flyer/Brochure/Newsletter Repeat contact Division of MRDD Staff Folder Internet I don't remember Conference/Display (please indicate which conference/display): Individual/Agency (please indicate which agency): We will contact you to discuss all of your support needs. Please indicate the type of match you are interested in: Traditional Parent to Parent/Peer Match (ongoing support match lasting at eight weeks with a minimum of four contacts from the mentor, by phone or email) Extended Match (ongoing support match lasting up to one year, with contact at least monthly) Quick Match (one time match to provide specific information on a topic or issue. Examples: community living, potty training, guardianship options) I Don't Know (we will help you determine the type of match that will be most beneficial to you and your circumstances) Comments / Questions: