Demographics
Name
Phone number
Email Address
Mailing address
Business Name
Support Broker Information
Authorization number #
Date Authorized
Do you have an employer-employee relationship with any fiscal intermediary or with OPWDD?
Are you providing brokerage services to self-directing individuals living in New York State?
Are you accepting new clients?
Are you certified as a housing navigator?
Number of individuals you support?
0-24
25-49
50-74
75+
Do you support budgets with housing? If so, how many?
Do you support budgets with SEMP? If so, how many?
Do you support any individuals living in certified settings?
Family Care? How Many?
IRA? How Many?
ICF? How Many?
Would you be interested in being a committee member?
Would you be interested in being a mentor for Alliance members?
Fluent in a language(s) other than English? Which?
Are there additional expert competencies you wish to disclose to the Alliance?
Are you affiliated with any other self-direction, I/DD organizations, or any advocacy groups (ex. SANYS, NY Alliance for Inclusion and Innovation?
Submit
NYISBA Questionnaire
