Online Intake Form

Other ways to contact us:

Phone: 1-800-779-2502 or Relay 711


Disability Rights Iowa
666 Walnut St, Ste 1440
Des Moines IA 50309

Online Intake Form

    I need Legal Help With:
    (Please see the Cases We Don't Handle before making your selection)

    Access to Assistive TechnologyDisability DiscriminationEducation - Special Education or Early InterventionEducation - Post-Secondary EducationEmployment DiscriminationGuardianship (Being My Own Guardian)Housing (Fair Housing Discrimination)Living in the CommunityRights in Institutions - Abuse & NeglectRights in Institutions - Other than Abuse & NeglectTransportationVotingOther

    Last Name (required)

    First Name (required)

    Street Address (required)

    City (required)

    State (required)

    Zip Code (required)


    Your Email (required)

    Preferred Method of Contact
    EmailPhoneNo Preference

    Permission to Leave a Message If You Would Prefer We Call You

    Are you filling this out for yourself or for someone else?

    If you are filling this out for someone else, what is your relationship to that person?

    If you are filling this out for someone else, what is their name?

    Do you or the person for whom you are filling out this form, have a disability?

    If yes, what is the disability?

    Your birthdate or the birthdate of the person for whom you are filling out this form

    Briefly Describe Your Problem (500 Character limit)

    Is any other agency or attorney representing or assisting you with this problem?

    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.

    What Next?

    After you complete this Online Intake Form, if you do not receive a reply from us within 3 working days, please contact us again by telephone, Relay 711, Fax, or regular mail at:

    Phone Numbers:
    1-800-779-2502 (Voice)
    Relay 711


    Disability Rights Iowa, ATTN: Intake, 666 Walnut St, Ste 1440, Des Moines, IA 50309