Intake Form

Full Name*
Street Address
County
Phone Number
Gender
Female
Male
Non-binary
City
Zip Code
Email Address*
Date of Birth*
Ethnicity/Race
Disability*
If disability is mental illness, please indicate diagnosis:
Was the diagnosis made by a qualified mental health professional (e.g., psychiatrist, psychologist, therapist, primary care physician, or other mental health professional)?
Yes
No
If it is a physical or mental disability: Did it occur before age 22?
Yes
No
Does it result in substantial limitations to any of the following (select all that apply):
Self-care
Receptive and expressive language
Learning
Self direction
Capacity for independent living
Economic self-sufficiency
If issue involves education, please list the school name and district:
Please indicate all that apply to you (or to the person with a disability if someone else is completing this form):
Registered Voter
Wants Assistance in Registering to Vote
Receives Supplemental Security Income (SSI)
Receives Social Security Disability Insurance (SSDI)
No longer receives SSI/ or SSDI but receives Medicare or Medicaid
Veteran
How many people live in the household of the person with a disability (including the person with a disability)?

Information About The Issue

Describe the problem(s) and how it relates to your disability. Include when the issue(s) arose.*
What you would like Native Disability Law Center to do? What would you like to happen?*
Name of any other agency assisting you and/or the person with a disability.
Is there any attorney assisting you and/or the person with a disability with this issue?
Yes
No
How can we contact you?*
Phone
Email
Letter
I would like someone that speaks....
English
Navajo
Other
Have you contacted us before?*
Yes
No

Information About Person Submitting Request (If Different from Person with Disability)

Full Name
City
Zip Code
Email Address*
Street Address
County
Phone Number
Relationship to Person with Disability

By completing this form, you are not automatically a client. All information you give us remains property of Native American Disability Law Center, Inc.

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