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Referral Form

The Center Towards Self Reliance (CTSR) is a nonprofit, consumer-led organizations that provide or coordinate services and supports for individuals with several types of disabilities (consumers).

To be eligible for most CTSR services, a person must have a disability. Eligibility is determined by the individual self-reporting at least one primary disability, describing how it impacts their daily lives, and a desire to maintain or improve their independence. Under the Rehabilitation Act, an individual with a disability is defined as a person who (1) has a physical or mental impairment that substantially limits one or more major life activities, (2) has a record of such an impairment, or (3) is regarded as having such an impairment. Major life activities include caring for oneself, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning. Everyone with a disability may not be eligible for our services at the exact time of referral. The consumer must participate in the planning process and consent physically, emotionally, and psychologically to service plans.

Screening Criteria

Please complete the form below and refer either yourself or someone else to CTSR. Please take the time to answer each of the questions.

Name of person being referred
What does the individual identify as their primary disability?
What areas does your disability or disabilities most inpact you?(Required)
Which area can we send you more information on?(Required)
This field is for validation purposes and should be left unchanged.
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