IL T&TA Center Intake Form

Please answer the following questions so we may best help you with your IL T&TA Center request

First Name

Last Name

Please enter your email address:
Note - A copy of your responses will be forwarded to the email provided.

Please re-enter your email address for confirmation:

Phone Number (optional)

State or Territory

Organization Name

Organization Type:
Please check all that apply.

Center for Independent Living (CIL)
Statewide Independent Living Council (SILC)
Designated State Entity (DSE)
Association of Centers for Independent Living
Person with a Disability
Family Member/Caregiver
Other, please specify

How did you hear about us?

Have you ever received assistance from us before?

Yes
No

Please select the type of assistance your organization is requesting:

Type of Assistance
Please check all that apply.

Request for Information or Materials
Training Request
Technical Assistance (Expert help for a need or problem in your organization)
Other (please specify):

Brief Description of Training or TA Request:
Please provide the issue you're facing and how long you have had this need.

Priority Level: (select one)

High (Needs Immediate attention; requires action within 1 - 2 days)
Medium (Important but not urgent; should be addressed within 3 - 5 days)
Low (Can be scheduled for later, should be addressed within 7 days)

Steps Already Taken: (if any)
What have you tried to resolve the issue so far?

Training Topic, Area of Interest, or Issue:
(e.g., CIL/SILC Board Operations, State Plan for Independent Living, Financial, Network Coordination, etc.)

For training requests, who would be the target audience?

If requesting training, please select your preferred mode of training:

Online (e.g., webinar, video conference)
Self-paced (e.g. recorded and or print material)
Other, What type of information is needed/and or the issue?

Skill Level (select one)

Beginner - 0-2 years of experience
Intermediate - 3-5 years of experience
Advanced - Over 5 years of experience

We'd love to hear more about the topic you're interested in! Please share any specific details so we may assist you better.