Intake Form | Disability Rights Pennsylvania

Person with Disability

Full Name*

Disability*

Gender

Male
Female
Non-Binary

Ethnicity/Race

Date of Birth*

Street Address*

City*

County

Zip Code*

Phone*

Name of person submitting request (if different from person with disability)

Street Address of Person Submitting Request (if different from person with disability)

City

County

Zip Code

Relationship of caller to person with disability

Email*

How can DRP contact you?*

Phone
Email
Video Relay
TTY

I would like to speak to someone that speaks...*

English
Spanish Yo hablo español
Vietnamese Tôi nói tiêng Việt
Other

Have you contacted DRP before?*

Yes
No

My problem/question involves:

Reason you are contacting DRP

Describe the problem and how it relates to your disability. Include when the issue arose.*

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

Describe any deadlines you may have. What is the deadline for? When is the deadline? (You are responsible for all deadlines)

Name of any other agency assisting you.

Is there an attorney assisting you with your problem/question?*

Yes
No

Please indicate all that apply to the person with disability:

Are you a registered voter?
Do you want to receive a voter registration form?
Do you receive Supplemental Security Income (SSI)?
Do you receive Social Security Disability Insurance (SSDI)?
Are you a veteran?

How many are in your household (including you)?

Is your income below $22,612.50

Yes
No

Is your income below $30,450.00

Yes
No

Is your income below $38,287.50

Yes
No

Is your income below $46,125.00

Yes
No

Is your income below $53,962.50

Yes
No

Is your income below $61,800.00

Yes
No

Is your income below $69,637.50

Yes
No

Is your income below $77,475.00

Yes
No

Submitting the Online Form and requesting assistance does not establish an attorney-client relationship with DRP. Due to limited resources, DRP unfortunately cannot provide services to all persons with disabilities requesting assistance.

Name

This field is for validation purposes and should be left unchanged.