The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

SHORT-TERM ASSISTANCE/INTAKE QUESTIONNAIRE
***Due to limited resources, DRC may not be able to directly assist you, but may only be able to give you information or referrals. Please continue to fill out the form if you would like to proceed.***
Your Name (First, Last)
Your answer
Potential Client Name (First, Last) - if self, please skip
Your answer
Relationship to Potential Client (Self, Parent, Conservator, etc...)
Your answer
Telephone:
Your answer
Email:
Your answer
Mailing Address: (Street, City, State, Zip Code)
Your answer
County of Residence:
Your answer
Did you hear about DRC from an outreach event?
INFORMATION ABOUT POTENTIAL CLIENT
Date of Birth:
MM
/
DD
/
YYYY
Primary Language:
Accommodation Needs:
Your answer
Regional Center Client?
If yes above, name of Regional Center:
Department of Rehabilitation (DOR) Client?
If yes above, DOR office branch:
Your answer
Check the topic area(s) that best represents your legal issue:
Youth:
Discrimination:
Work Incentives
Mental Health
Healthcare and Long-term Supports and Services
Regional Center
Voting:
Disability Rights California will use this information to contact you within one business day after you submit this form. If you have any deadlines, please list them here.
Your answer
Do you need Disability Rights California to reach you in some way other than by phone? (if you answer "yes" let us know your preference in the following questions)
Please explain why:
Your answer
How should Disability Rights California contact you?
Areas where Disability Rights California CANNOT provide assistance
1. Direct representation in criminal law, family law, bankruptcy or evictions
2. Personal Injury (including workers’ compensation)
3. Medical Malpractice (wants to sue doctor/hospital/clinic)
4. Social Security eligibility and eligibility appeals, including filling out application forms
5. Obtaining a guardianship or conservatorship
6. Wills and trusts, including special needs trusts
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms