Request Help

Request Help

Missouri Protection and Advocacy Services (Mo P&A)
Form Instructions

Fill out this form if you need help protecting your rights. When you submit this form, the Mo P&A Application Unit will receive your request for help. Someone from our Application Unit will reach out to discuss your issue and what you need from us. Mo P&A will look at your request to decide how we can help.

The questions on this form help us understand what you need help with, and how Mo P&A can best help you. We also need some of this information to meet the requirements of our federal funders.

Please answer as many questions as you can on this form. This helps us process your request so that we can provide information or other help as soon as possible.

If you are not the person with a disability that needs help:

You can fill out this form on behalf of a person with a disability, but we will need to talk to that person directly before Mo P&A can provide services.

Please answer the questions on this form using the information for the person with a disability. Then provide your contact information when requested at the end of the form.

If you want to request services for a group of people with disabilities:

To request services or systemic activities on behalf of a group of people with disabilities, please contact the Mo P&A Application Unit directly. Groups can include residents of a specific facility, people receiving disability services from a specific agency, etc.

Contact the Mo P&A Application Unit

If you need help filling out this form, or if you want to request help a different way, you can contact us directly.
- Call toll-free at 800-392-8667
- TDD users can call 800-735-2966
- Email app.unit@mo-pa.org
- Mail a letter to: Application Unit, 925 South Country Club Drive, Jefferson City, MO 65109
Disclaimers

Attorney-Client Relationship Disclaimer

Submitting this Request Help form does not create a contract for services.

Submitting this Request Help form does not create an attorney-client relationship with Missouri Protection and Advocacy Services.

Confidentiality Notice

All requests for services are kept strictly confidential.

This form is protected by a 256-bit Secure Socket Layer (SSL) connection that uses a SHA256 Certificate. Only designated Mo P&A employees have access to form submissions, including any documents uploaded to a form.

This form is also encrypted with high-grade RSA 2048 algorithm. Your information is encrypted while you are filling out the form. Your information is also encrypted when you submit the form.

Mo P&A also stores your request for services in secure cloud storage that complies with the U.S. Federal Government's Federal Risk and Authorization Management Program (FedRAMP).

If you don't feel comfortable entering certain information online, you can leave most fields blank. But some fields are required for Mo P&A to process your request, such as your name, how to contact you, and what you need help with.

Who we cannot help

Mo P&A cannot provide advocacy or legal services if you request help with the following:
- Providing case management
- Establishing guardianship
- Criminal law
- Family law (divorces, adoptions, wills, etc.)
- Personal injury lawsuits if the only compensation is money
- Any lawsuit that is not related to a disability
Mo P&A cannot duplicate advocacy or legal services. This means we cannot provide these services to help with your issue if you are already:
- A current applicant or client of Mo P&A for that issue,
- Receiving services from another attorney for that issue, or
- Getting help from a private individual for that issue.
Date of Request Help Form

MonthDayYear
I have read and accept the above disclaimers*

I accept
Are you the person with a disability that needs help? Or are you filling out this form on behalf of a person with a disability?*

I am the person with a disability that needs helpI am the guardian of a person with a disabilityI am the parent of a child with a disabilityOther (Enter your relationship to the person with a disability below)

Contact Information of Person Completing This Form
Name (If you need to remain anonymous, please enter "Anonymous" in the fields below)*

First NameLast Name
Do you live or work in a facility or other agency that provides disability-related services?

YesNo
Please enter the name of the facility or agency:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Other Phone Number (Include extension if applicable)

Area CodePhone Number
Email Address
example@example.com

Submit Your Online Request for Help
Submitting this Request Help form does not create a contract for services.

Submitting this Request Help form does not create an attorney-client relationship with Missouri Protection and Advocacy Services.

When you click the Submit button below, the Mo P&A Application Unit will receive your request for help. Someone from our Application Unit will reach out to discuss your issue and what you need from us.

Mo P&A staff will look at your request, then decide how we can help. Sometimes this means we will provide Information and Referral services. Sometimes this means an Advocate or Attorney will provide direct services.

If you are not eligible for services, or if Mo P&A is not able to help with your problem, we will send you a letter explaining our decision. This letter will also explain Mo P&A's Grievance Policy.
Please verify that you are human*
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