DDSIRW suggestions and participation interest form

The Department of Behavioral Health and Developmental Services (DBHDS) is seeking your input and participation in determining actions that can be taken to improve the DD system of supports and services in Virginia. We are asking individuals and families to answer the questions below and if you are interested in being on a workgroup, please complete question 5. DBHDS will select 50 participants to assist with this effort. Additional options to observe and comment will be provided to those not selected and the public at large.

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* 1. Select the appropriate response from the drop down menu below. If other, please specify in the space provided.

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* 2. Enter the city or county where you live.

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* 3. Please select your age group (or the age group of the individual if you are family).

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* 4. How would you describe your disability? (check all that apply)

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* 5. If you have a DD Waiver, which waiver do you have?

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* 6. Which type(s) of services do you (or your family member) receive? (check all that apply)

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* 7. Think about what you believe DBHDS can do to improve the DD system. Describe your first idea below.

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* 8. Describe a second idea.

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* 9. Describe a third idea.

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* 10. If you are interested in participating in the workgroup, please provide your contact information below.

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