Intake Form

Your Name*

First Name Last Name

Do you work with an organization?*

Your Organization*

Your Title / Position at Your Organization*

Your Street Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How would you like us to contact you?*

Mobile Phone Number (SMS Capable)*

This is mandatory as you selected Text Message / SMS as your preferred contact method.

Your Email

example@example.com - This field is mandatory if you selected email as your preferred contact method. Please note that if you would like to receive a digital copy of this form submission, you will need to enter a valid email address in this field.

Your Phone Number

Please enter a valid phone number. This field is mandatory if you selected phone as your preferred contact method.

Alternate Phone Number (Optional)

Please enter a valid phone number.

Your Relationship to the Person with a Disability*

For example: parent, sibling, service provider,supports coordinator, advocate, treatment professional, etc.

Name of Person with a Disability*

First Name Last Name

Gender of Person with a Disability*

Ethnicity of Person with a Disability*

Race of Person with a Disability*

Preferred Language of Person with a Disability*

Preferred Language (Other - Please Specify)*

Date of Birth of Person with a Disability*

MonthDay Year

Street Address of Person with a Disability*

Street Address

Street Address Line 2

City State

Zip Code

Phone Number of the Person with a Disability

Please enter a valid phone number.

Email of the Person with a Disability

example@example.com

Living Arrangement of the Person with a Disability*

Living Arrangement - Other (Please Specify)*

Disability / Diagnosis of the Person with a Disability*

Please list all that apply. For example, intellectual disability (ID), mental illness, orthopedic impairment, deaf, TBI...

How many people live in the Person with a Disability Household, Including the Person with a Disability?

What is the total household income annually of the Person with a Disability?

Is the Person with a Disability a Registered Voter?*

Would the Person with a Disability Like Information or Assistance to Register to Vote?*

Please list any voting assistance needed*

Does the Person with a Disability have a serious mental illness or emotional impairment that has been diagnosed by a qualified mental health professional?*

What Serious Mental Illness and/or Emotional Impairments has the Person with a Disability been diagnosed with? *

Which qualified mental health professional made this diagnosis*

Please specify which other qualified mental health professional made this diagnosis*

Is the Person with a Disability in active treatment now or ever in the past?*

Is the Person with a Disability able to*

	Yes	No
Work and earn an income?
Live Independently?
Communicate with others through talking, writing, or using sign language?
Learn new things without difficulty?
Walk or move without difficulty?
Perform daily living skills without help? For example, eating, showering, cooking, etc.
Make decisions without help? For example, choose your daily activities, determine when you need to see a doctor?

Did the disability occur before the age of 22?*

Is the Person with a Disability receiving any of the Social Security benefits listed below? (select all that they receive)*

SSDISSIN/A or Does not Apply

Has the Person with a Disability stopped receiving Social Security benefits (SSDI or SSI) but still have Medicaid (MA) or Medicare?*

Is the Person with a Disability on Medicaid (MA)?*

Is the Person with a Disability a veteran?*

What is the issue you are contacting us about today?*

Please provide as many details as possible to help us determine how we can help you.

What you would like DRP to do? What would you like to happen?*

Please provide as many details as possible to help us determine how we can help you

Does the Person with a Disability have an attorney helping you with this issue?*

Is anyone else helping the Person with a Disability with this issue?*

Who else is helping the Person with a Disability with this issue?*

How did you find out about DRP?

Intake Form

SMS NOTICE

SMS NOTICE