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 contact you after submitting an intake request form.

First Name*

Last Name*

Phone Number:*

Date of Birth*

Your Name (if submitting on behalf of someone else)

Address*

City*

State*

Zip*

Email Address

Race*

Ethnicity*

Sexual Orientation

Gender*

Female

Male

Other

Pronouns

Gender Identity

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.

Disability Rights Vermont

141 Main Street, Ste 7 Montpelier, VT 05602
Toll Free: 1-800-834-7890
Phone or Text: 1-802-229-1355
info@disabilityrightsvt.org

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Disability Rights Vermont

141 Main Street, Ste 7 Montpelier, VT 05602
Toll Free: 1-800-834-7890
Phone or Text: 1-802-229-1355
info@disabilityrightsvt.org

Facebook
Mail
Instagram
Twitter

Neve | Powered by WordPress

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