Intake Form

I understand that by completing and submitting this Intake Form, I am applying for services from DRSD. Submitting this Intake Form does not create an attorney-client relationship. Disability Rights South Dakota has a centralized intake process. All people seeking to become clients of this agency must first go through the intake process. That process can be initiated by submitting this Intake Form or by contacting the Intake Team at 1-800-658-4782. The Intake Team makes decisions about who the agency will assist or represent based on eligibility, program priorities, and available resources. Disability Rights South Dakota will keep the information in this Intake/Application confidential. If DRSD agrees to assist or provide legal representation to you, DRSD will send you a Letter of Understanding and/or Representation Agreement to sign.

Name of Person Needing Services *

Name of Contact Person or Person Entering Information *

Mailing Address

City

State

Postal code

Telephone / Contact Number *

Alternate Telephone / Contact Number

Email *

Date of Birth

*Disclaimer* Our funders have asked us to collect some demographic information, it's optional and will only be used to help ensure we are being inclusive and equitable. You can select "prefer not to answer" any questions about Sexual Orientation or Gender Identity. Making this selection will not have any impact on our determination on providing services or any aspect of our services should your issue be assigned to advocacy staff.

Sexual Orientation *

Gender Identity *

Ethnicity

Are you a Veteran? *

Living Arrangements *

Are you or the person you are calling about in a facility? *

If Yes, which one?

Do you, or the person needing services, receive any of the following?

Special Education Services

SSDI

SSI

Are you, or the person needing services, registered to vote? *

Reason You Are Contacting Disability Rights South Dakota

Please describe the problem and how it is related to the person's disability and when it happened:

Describe any deadlines you have. You are responsible for all deadlines:

Name of Agency Assisting You, If Any

Is there an attorney assisting you with your issue? *