wei@habcnj.org
One Bergen County Plaza, 2nd Floor, Hackensack, NJ, 07601, US
201-336-7600
Are you Disabled?
If Yes, please choose all that apply.
Primary language?
Are you or any adult member in your household able to participate in an English language remote briefing?
Are you able to and voluntarily choose to use the assistance of an adult family or friend to assist in language translation?
Do you are any other adult member of your household have access to a computer, laptop, tablet, and/or smartphone with a front facing camera?
Are you able to and voluntarily choose to use devices of family & friends?
Do you have access to internet?
Are you able to and voluntarily elect to use internet access of family and friends?
Are you able to participate in a Video conferencing remote briefing via internet Zoom meeting?
HABC will work to accommodate an in-person briefing appointment
How would you like any requested documents delivered?
Are you or someone assisting you in the completion of this form?
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