Test Contact Form Online Intake Form "*" indicates required fields Case SelectionTo be eligible for DRI services you must meet all the eligibility criteria – be an individual with a disability, have a disability-rights related issue, and that issue must fall under one of our Areas of Focus. If eligible, DRI will consider whether there is adequate personnel and funds to zealously handle the request for assistance.Cases DRI can Consider*DRI may only consider requests that meet the above criteria. Access to Assistive Technology Accessibility of Service or Place Education (special or K-12) Higher Education (after high school) Ensuring Workplace Reasonable Accommodations Living in the Community Problems with a Guardian or Conservator Problem with a Representative Payee Rights in Residential Facilities Rights in Home and Community Based Service Settings Healthcare Voting Benefits Planning Other (Not listed here) Cases DRI cannot takeDRI does not provide assistance in the following areas. DRI might be able to provide only a referral in these areas. Family Law; divorce, child custody, etc. Bankruptcy Estate Planning Criminal or juvenile delinquency Civil Mental Health Committals Termination of parental rights Child in Need of Assistance Cases Housing Tax law, business or consumer law Personal Injury Malpractice Social Security eligibility or appeals Workers compensation cases Civil litigation unrelated to disability Employment discrimination civil litigation Initiation of guardianship general issues of prisoners Thank you for Contacting DRI* We do not accept cases on the issue that you have selected. If you would like DRI to provide you with referrals to other entities which may be able to help you, or self-advocacy resources please provide your contact information. Check this box to acknowledge DRI cannot assist with your issue.Personal IdentificationFirst Name* Last Name* Pronouns Street Address* City* State* Zip Code* Phone*Personal Email* Preferred method of contact* Email Phone No Preference Do we have permission to leave a message?* Yes No Who are you completing this form for?* Myself Someone Else Additional InformationWhat is the name of the individual you are filling this form out for?* Pronouns, if known What is your relationship with the person you are filling this form out for?* What is the date of birth for the individual?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Disability IdentificationEnter your date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you or the person you are requesting services for have a disability? Yes No What disabilities have been diagnosed?* Briefly describe the problem*What would you like DRI to do for you?Is any other agency or attorney representing or assisting you with this problem?*How did you hear about us?*Terms & Conditions* I understand that this is an application for services. The application does not create an attorney-client relationship. Disability Rights Iowa will keep the information in this application confidential. If DRI agrees to provide legal services to you, DRI will send you a separate agreement to sign.
