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Online Intake Form

Please complete as much inforrmation as possible. If you have any difficulties using this form, please feel free to contact us via phone at (800) 342-0823 or via TDD at (800) 346-4127.

Items with an asterisk (*) are required

Information Related To The Person With A Disability

Current Disability Benefits

Select all disabilities that apply

Are you registered to vote?

Contact Information
Enter "NONE" if you don't have a phone.
Enter "NONE" if you don't have an email.
*Living Arrangement

If you are in a facility:

Reason you are contacting the Advocacy Center
*Please briefly describe the problem that is related to the person's disability including when it happened:
Name and phone number of any agency assisting you in this matter
None
Yes, an agency is assisting me
 
Name and phone number of any attorney assisting you in the matter
None
Yes, an attorney is assisting me
 
Name and phone number of any advocate assisting you in the matter
None
Yes, an advocate is assisting me
 
Describe any deadlines you have. You are responsible for all deadlines.
Persons Completing Form on Behalf of Person with Disability

If you are contacting the Advocacy Center about an individual with a disability, and you are the parent or guardian, or the individual is unable to make contact due to his/her disability, you are required to complete the following information about yourself.

By submitting this I certify the above to be true

or