Intake Form - Disability Rights Pennsylvania

Information About The Person With Disability

Full Name*

Street Address

City

County

Zip Code

Phone*

Email Address*

Gender

Male
Female
Non-Binary

Ethnicity/Race

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Two or more races
Other
Decline to Answer

Date of Birth*

Disability*

If disability is mental illness, please indicate diagnosis:

Was the diagnosis made by a qualified mental health professional (e.g., psychiatrist, psychologist, therapist, primary care physician, or other mental health professional)?

Yes
No

If it is a physical or mental disability: Did it occur before age 22?

Yes
No

Does it result in substantial limitations to any of the following

Self-care
Receptive and expressive language
Learning
Mobility
Self-direction
Capacity for independent living
Economic self-sufficiency

Check all that apply

If issue involves education, please list the school name and district:

Please indicate all that apply to you (or to the person with a disability if someone else is completing this form):

Registered voter
Wants assistance in registering to vote
Receives Supplemental Security Income (SSI)
Receives Social Security Disability Insurance (SSDI)
No longer receives SSI/ or SSDI but receives Medicare or Medicaid
Veteran

How many people live in the household of the person with a disability (including the person with a disability)?

Information About The Issue

Describe the problem(s) and how it relates to your disability. Include when the issue(s) arose.

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

Name of any other agency assisting you and/or the person with a disability.

Is there any attorney assisting you and/or the person with a disability with this issue?

Yes
No

How can DRP contact you?*

Phone
Email
Letter

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

Information About Person Submitting Request (If Different from Person with Disability)

Full Name

Street Address

City

County

Zip Code

Phone Number

Email Address

Relationship to Person with Disability

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.

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Name

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