Please list the date you received support from PremierFMS
What is your role in Self-Direction?
Which state is your program located?
Select one... Arizona Arkansas Colorado Louisiana Michigan Oregon Texas Utah Washington West Virginia Wisconsin Wyoming
Which Colorado program did you receive support from?
Select one... The Independence Center Veteran-Directed Care Hilltop Veteran-Directed Care
Which Texas program did you receive support from?
Select one... Harris County Area Agency on Aging Veteran Directed Care CADDO Veteran-Directed Home and Community Based Services
Which Utah program did you receive support from?
Select one... Employee-Related Personal Assistant Services (EPAS) Division of Services of People with Disabilities (DSPD) New Choices Waiver (NCW) Technology Dependent Waiver (TDW) Medically Complex Children's Waiver (MCCW) Aging Waiver
Which Washington program did you receive support from?
Select one... Center for Independence Central Washington Disability Services
Which Wisconsin program did you receive support from?
Select one... Include, Respect, I Self-Direct (IRIS) My Choice Family Care Children's Long-Term Support (CLTS) Independent Living Supports Pilot (ILSP)
Please tell us about your experience with PremierFMS and who you received support from.
Would you be willing to share a photo of yourself for PremierFMS marketing purposes (i.e. testimonial board, feature stories, etc.)? If yes, please read and check the following Photo Release Agreement.
Photo Upload (format - jpg, jpeg, jpe, or png)
Photo Release Agreement
Would you be willing to be talk with someone from PremierFMS so we can learn more about your experience?
Can PremierFMS use the information provided in this form to share your story for marketing purposes (i.e. testimonial boards, feature stories, etc)? If yes, please read and check the following Testimonial Agreement.
How would you prefer to be contacted?
What day or days work best for a phone call (choose up to 3)?
What time of day works best for you?
If you are human, leave this field blank.