Request Services | DSB - Wa Dept of Services for the Blind

SELF-REQUEST FOR SERVICES FORM

If you are interested in learning more about DSB services for yourself or a loved-one, please provide the information below. A DSB representative will contact you.

Please do not provide any sensitive, personal, or medical information on this form.

Your Contact Information

Name

Email

Phone

City/Town

State/Province

County

Age

How did you learn about DSB?

Are you or the individual being referred currently employed or interested in becoming employed and/or attending school?

Yes

No

Maybe

Referrer

If you are filling out this form for a friend or loved one, please provide the following information:

Referrer name (The name of the person filling out this form.)

Referrer phone number