If you’re a person with a disability and need help protecting your rights, you can use this form to tell us what’s going on. This is called an “intake.” It’s how we learn about your situation and see if we can help.

If you’re a service provider, family member, or someone else filling this out for another person, please complete the form using their information. Be sure to include your name in the “Your Name (if submitting on behalf of someone else)” line.

Disability Rights Vermont collects demographic information for federal reporting and program administration purposes. This information helps us understand who is accessing our services and identify whether there are barriers to accessing services across Vermont. Your responses, or your decision not to respond, will not affect your eligibility for services or the assistance we may provide.

Once you submit the form, someone from Disability Rights Vermont will review it and get back to you as soon as possible.