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)

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Phone(required)

Your Email (required)

Preferred Method of Contact
EmailPhoneNo Preference

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

Are you filling this out for yourself or for someone else?
---MyselfSomeone 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?
---YesNo

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.