Intake Form

Complete our online intake form and click Submit when you are finished.

DRP needs information related to the person with a disability to determine eligibility for services and for our statistical reporting purposes. All information provided is confidential. Providing us with complete and detailed information about the person with the disability will allow us to respond to you more quickly and efficiently. Questions marked with an (*) must be answered. You will not be able to submit the form unless the required information is filled in (you can answer "don't know", "prefer not to disclose", or "does not apply" if necessary). If you are unable to complete the questions without assistance, please call 800-692-7443.

We provide an array of services to eligible individuals on issues that fall within our priorities and our case selection criteria. DRP does not charge for services. DRP cannot assist every individual who contacts us, but you should hear back from a DRP staff person within 10 (ten) business days of your request. Click here to learn when DRP Intake Services will not be available.

Effective November 1, 2025, and until further notice, DRP will only be able to provide limited services to many individuals who contact our intake system for assistance. This is due to the federal government shutdown which has delayed the release of key federal funding that supports our ability to provide a higher level of services to our intake clients who have issues that fall within our organizational priorities and areas of expertise.

If you contact DRP's intake system for help during the federal government shutdown, we may only be able to provide information, advice, and referral during the initial phone call (or in one written response to online inquires). You should not expect additional follow-up calls or information from DRP staff, but you may file a grievance if you are not satisfied with our services.

We expect to resume our typical intake system services once the federal shutdown is over and we can access our federal funding again. We will notify the public once that happens. In the meantime, we appreciate your patience and understanding.

A Person with a DisabilityContacting DRP on Behalf of a Person with a Disability

Street Address

Street Address Line 2

CityState

Zip Code

This is mandatory as you selected Text Message / SMS as your preferred contact method.

example@example.com - This field is mandatory if you selected email as your preferred contact method. Please note that if you would like to receive a digital copy of this form submission, you will need to enter a valid email address in this field.

Please enter a valid phone number. This field is mandatory if you selected phone as your preferred contact method.

Please enter a valid phone number.

Please list all that apply. For example, intellectual disability (ID), mental illness, orthopedic impairment, deaf, TBI...

	Yes	No
Work and earn an income?
Live Independently?
Communicate with others through talking, writing, or using sign language?
Learn new things without difficulty?
Walk or move without difficulty?
Perform daily living skills without help? For example, eating, showering, cooking, etc.
Make decisions without help? For example, choose your daily activities, determine when you need to see a doctor?

SSDISSIN/A or Does not Apply

Please provide as many details as possible to help us determine how we can help you.

Please provide as many details as possible to help us determine how we can help you

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This is mandatory as you selected Text Message / SMS as your preferred contact method.

Please enter a valid phone number. This field is mandatory if you selected phone as your preferred contact method.

Please enter a valid phone number.

For example: parent, sibling, service provider,supports coordinator, advocate, treatment professional, etc.

Street Address

Street Address Line 2

CityState

Zip Code

Please enter a valid phone number.

Please list all that apply. For example, intellectual disability (ID), mental illness, orthopedic impairment, deaf, TBI...

	Yes	No
Work and earn an income?
Live Independently?
Communicate with others through talking, writing, or using sign language?
Learn new things without difficulty?
Walk or move without difficulty?
Perform daily living skills without help? For example, eating, showering, cooking, etc.
Make decisions without help? For example, choose your daily activities, determine when you need to see a doctor?

SSDISSIN/A or Does not Apply

Please provide as many details as possible to help us determine how we can help you.

Please provide as many details as possible to help us determine how we can help you

Intake Form

SMS NOTICE

SMS NOTICE