The Arc of Texas: Survey - Update Your Benefits

1.

Name on Account

*

Name:

First Required	Last Required

*

Email: Required

Yes, I would like to receive e-mail from The Arc of Texas

2.

Question - Not Required - Account Number

3.

Question - Not Required - Current Government Benefits: (Please check ALL that apply)
Please make up to 2 selections from the choices below.

	SSI
	SSDI

*4.

Question - Required - Do you receive Medicaid?

5.

Question - Not Required - If yes, please choose which kind: (Please check ALL that apply)
Please make up to 6 selections from the choices below.

6.

Question - Not Required - If other, please explain:

7.

Question - Not Required - Other Services: (Please check ALL that apply)
Please make up to 3 selections from the choices below.

8.

Question - Not Required - If other, please explain:

(Maximum response 255 chars, approx. 5 rows of text)

9.

Question - Not Required - Other Insurance:

(Maximum response 255 chars, approx. 5 rows of text)

The Arc of Texas