HiddenInvoice Number: Please use the first two letters of first and last name followed by the date of birthCounty Of Residence: Year Of Birth Primary Language Gender Male Female Self Identify Decline To state Self Identify Race Ethnicity African American / Black Pacific Asian Caucasian / White East Indian Hispanic Native American Pacific Islander Decline To State Other Race Ethnicity (Other) What is the nature of your disability: Amyotrophic Lateral Sclerosis (ALS) Aphasia Apraxia Autism Cerebral Palsy Development Disability Dysarthria Huntington’s Disease Larynx Disorder Muscle Weakness Oral Cancer Stroke Stuttering-Stammering Traumatic Brain Injury Vocal Cord Damage Other: What is the nature of your disability (Other) How did the applicant first hear about the Voice Options Program? ILC AT Center Medical Provider Social Media Other: How Did The Applicant Hear From Us (Other) For which of the Following purposes did you use your iPad and speech application, check all that apply: Call in a prescription refill Attend video appointment Call to schedule an appointment Call contact friends/family Call your bank Call to make a purchase Other: Using iPad For Speech Application (Other) CAPTCHA Δ
