Client Intake Questionnaire
If you need the assistance of a competent disability advocate, please fill out the intake questionnaire below and submit it to us and we will have one of our advocates contact you as quickly as possible.

We serve people with all kinds of disabilities and their relatives, associates, and friends

CONFIDENTIALITY IS ASSURED

By filling out this form and clicking on the submit button below, you understand that you are sending information to us that will assist the Orange County Deaf Advocacy Center to bring resolution to your situation. You also understand that clicking on the submit button below you are requesting an advocate-client relationship be established between you and Orange County Deaf Advocacy Center and you also understand that all information sent is confidential.

Name *
Please enter your full name.
Your answer
E-mail Address *
Please enter a vaild e-mail address
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
The Urgency Of My Situation is *
My Disability(ies) Are: *
Check All That Apply
Required
I receive Public Assistance through: *
Required
I Need The Following Services: *
Check All That Apply
Required
Age *
Please choose the age of the person you are appling for.
Ethnicity *
Income Range *
Language *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.