Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of individual with the disability: *FirstLastThis Online Intake Form does not create an attorney-client relationship with DLC. DLC will review your Online Intake Form to consider what help we can offer.Telephone number of the individual with the disability: *Email of the individual with the disability: *Date of birth of the individual with the disability: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please describe the disability: *Address of the individual with the disability: *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is the preferred language of the individual with the disability:EnglishASLSpanishOtherWhat is the language of the individual with the disability:Problem Area:Abuse or NeglectAccess to Durable Medical EquipmentAccess to Services for SSA Beneficiaries (NOTE: DLC does not help with applications for benefits or appealing denials)Communication Access in Healthcare ServicesHuman rights violations in hospitals, nursing homes, group homes etc.Reasonable Accommodations (in housing, employment, etc.)Voting AccessOtherPlease explain the Problem Area if 'Other' was selected:Describe the problem and how it relates to your disability. When did the problem start or incident occur? *What would you like DLC to do? What would you like to happen? *Describe any deadlines. What is the deadline for? When is the deadline? (You are responsible for all deadlines.)Is there any one helping with this issue and is there an attorney involved? *Do you have any concerns about your representative payee?YesNoNot applicableIf you are not the individual with the disability, state your name:FirstLastPhoneEmailYour relationship to the individual with the disability:Case WorkerI am the individual with the disabilityChild (of the person with the disability)GrandparentLegal GuardianOtherParentSiblingSocial WorkerSpouse/PartnerBy checking this box, I agree to receive SMS content (text messages) from DLC *I agree.I do NOT agree.NameSubmit Share
