Date:

SOME QUESTIONS ABOUT YOU

Name:

Address

City

State:

Zip

Country

Home phone

Work phone

E-mail address

Sex

M F

Age

Date of birth

Height

Weight

Hair

Eyes

Physical Build

Small
Medium
Large

Education completed
(check those which apply)

Elementary
Jr. high
High School
Vocational
Jr. College
College
Graduate School

Certificates & degrees

Currently attending? (explain)

Occupation

Currently employed

yes, no

Volunteer work? (explain)

Annual income range (select one)

Are you receiving SSDI benefits?

yes, no

Ever married?

yes, no

When divorced?

month year .

Currently separated?

yes, no, N/A. If yes, how long?

Any children?

yes, no. If yes, children's ages:

Any other dependents?

yes, no

Your current living arrangements (select one)

Have you ever been convicted of a crime?

yes, no

If so, explain

SOME QUESTIONS ABOUT YOUR DISABILITY

Disability (check those which apply)

Do you use any of the following (check those which apply):

SOME QUESTIONS ABOUT YOUR ATTITUDES AND PREFERENCES

What kind of relationship are you seeking
(check one or more):

Friendship
Romance
Long Term Relationship
Marriage

Age range of person you are willing to meet
(check one or more):

20-30
30-40
40-50
50-60
60-70
Over 70

Do you smoke?

yes, no

Would you date someone who smokes?

yes, no

Do you drink?

yes, no

Would you date someone who drinks?

yes, no

Would you date someone with children or other dependents?

yes, no

Would you date someone who is
divorced or separated?

yes, no

What is your race?

Would you date someone of another race?

yes, no

Do you adhere to a particular religion?

yes, no

Which?

Would you date someone of another religion?

yes, no

Would you date an atheist?

yes, no

Do you wish to state a sexual preference (select one):

heterosexual homosexual bisexual
no preference

How do you consider yourself (select one):

How would you describe yourself (select one):

Please indicated your preferences among the following:

Describe the type of person you are looking for with specific reference to physical appearance, intelligence, and other characteristics you desire:

SOME QUESTIONS ABOUT YOUR OUTLOOK

Do you feel you have accepted yourself and your limitations?

yes,no

Explain:

Do you have any reservations regarding the disability of the person you are willing to meet? (be specific):

If you are not differently abled, why would you like to meet a person with a disability? Explain:

Below, please write a personal profile of yourself to be read by prospective referrals. Indicate YOUR FIRST NAME ONLY. Describe your personality, disability, likes, dislikes, outlook on life, and future hopes.

You have two options regarding phone contact with prospective referrals. Select one of the following:

We will include your phone number on your profile sent to prospective referrals

We will delay three days before your phone number is available to a referral upon request, giving you time to decline the contact by phoning our office.

You can send this form immediately by clicking below.