Request Assistance from DRW

If you provide an email address, an email confirmation that your request was received will be sent to you.

While the Date of Birth and Disability fields are optional to complete, it will greatly assist DRW in determining which of our programs is best suited to follow up with your request.

Your Name (required)

How Should We Contact You? (required)

Your Phone Number

Please enter a valid phone number including area code

Your Email Address

Your Location (County or City/Town) (required)

Who is the person with a disability you are requesting assistance for? (required)

I am the person with a disability who needs assistanceI am requesting assistance for someone else

Name of person with a disability (required)

Your relationship to this person (required)

Date of Birth (optional)

Disability (optional)

What issue or concern would you like assistance with? (required)

0/1000

By checking the box below this statement, you acknowledge you are requesting assistance from Disability Rights Wisconsin. This submission does not create a client relationship or guarantee DRW will be able to assist you. *

I understand this statement, and I wish to submit my request for assistance (required)

Relationship

ContactMethod

County

DateSubmitted

Date

Hour Minutes

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