REQUEST INFORMATION OR SUPPORT
The State of Michigan's health system for the developmentally disabled is not an easy environment to negotiate.
The Association for the Macomb-Oakland Regional Center (AMORC) is here to help consumers, along with their families and friends, gain access to relevant, timely and accurate information so they fully understand and make use of the support services available to them.
(Items in blue are required.)
(1)
Please check each of the areas for which you need information and/or support.
Education and Training
Employment
Family Support
Housing
Legal Assistance/Consumer Rights
Managed Care
Resources
Service Providers
Transportation
Other
(2)
In the box below, please briefly describe the specific information or support you require.
(3)
Which one of the constituent types below best describes you?
Consumer
Family member or legal guardian of a consumer
Friend of a consumer
Service provider
Volunteer
Government official
Other interested party
(4)
In the space below, provide an e-mail address or telephone number so that someone can contact you regarding your request.
The following information is requested so that we may tailor our information and services to meet the needs of our various constituencies.
The information you provide is kept in strictest confidence, is maintained on a secure site and is not used by AMORC or any third-party organization for solicitation or any other invasive purpose.
You may also leave a telephone message with AMORC at 248-276-8178. Or, drop us an e-mail at amorc@theamorc.org.
City
State/Province
Zip/Postal Code
Country
Type of residence
Select One:
Rent House
Own House
Rent Apartment
Own Apartment
Rent Condominium
Own Condominium
Lease Condominium
Other
Gender
Select One:
Male
Female
Age
Select One:
<18
18-20
21-35
36-45
46-60
61-65
>65
Marital status
Select One:
Single
Married
Divorced
Household income
Select One:
<$25000
$25000 to $49000
$50000 to $99000
$100000 to $149000
$150000 to $249000
>$250000
Employment status
Select One:
Full-time Employed
Part-time Employed
Self-Employed
Business Owner
Unemployed
Retired
Attending Trade School
Attending College
Other household members - Spouse
Yes
No
Other household members - less than 18 years old
Select One:
0
1
2
3
4
5
6
7
8
9
10
Other household members - 18 years or older
Select One:
0
1
2
3
4
5
6
7
8
9
10
Ethnic Background
Select One:
Caucasian
Hispanic
Afro-American
Asian
American Indian
Other
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