Which program are you receiving support from?
What is your role in Self-Direction?
Would you be willing to share a photo of yourself for PAS marketing purposes (i.e. testimonial board, feature stories, etc.)? If yes, please read and check the following Photo Release Agreement.
Would you be willing to talk with someone from PAS so we can learn more about your experience?
Can PAS use the information provided in this form to share your story for marketing purposes (i.e. testimonial boards, feature stories, etc)? If yes, please read and check the following Testimonial Agreement.
How would you prefer to be contacted?
What day or days work best for a phone call (choose up to 3)?
What time of day works best for you?