Intake Request Form

Please note that DRVT is not able to accept all requests for assistance. Information about the types of issues we may be able to assist with is available on our Services page. A staff member will reach out to you once an intake request form has been submitted.

First Name*

Last Name*

Phone Number:*

Date of Birth*

Address*

City*

State*

Email Address*

Race*

Ethnicity*

Gender*

Female

Male

Other

Pronouns

Disability/Diagnosis*

Employment Status

Education Level

Do you receive Social Security benefits?*

SSI

SSDI

None

Unknown

Are you a Veteran?*

Yes

Unknown

Have you been vaccinated for COVID-19?

Yes

Unknown

How would you like us to contact you?*

Phone

SMS/Text

How did you hear about us?

Please describe the reason that you are requesting assistance:*

I understand that DRVT does not represent me on any issues related to this request for services. I understand that submitting this request for services does not create an attorney-client relationship with DRVT.*

Yes, I agree with the above terms and conditions.

Reach out to us for
assistance.

Mailing address:
141 Main Street Suite 7
Montpelier, VT 05602

Phone Numbers:
(800) 834-7890
(802) 229-1355
(802) 229-1359 fax

Email Address
info@disabilityrightsvt.org

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Intake Request Form

Reach out to us forassistance.

Reach out to us for
assistance.