Information and Advocacy Program Intake Form

The Information and Advocacy Program provides information, referrals, and advocacy support to people with disabilities of all ages, as well as their families and caregivers. We can help you access services, complete applications and forms, and navigate challenges related to disability services, benefits, and community supports. Please complete the Client Intake Form below to get started. We respect your privacy and keep your information strictly confidential at all times.

Information & Advocacy Intake Form

Date of intake *

Client Contact Information

First Name *

Last Name *

Are you seeking assistance for the person listed above?

Yes

If you answered NO to above, what is the full name of the person this is regarding:

Relationship to client Relationship to client

Email *

Phone – Primary *

Phone – Secondary

Address *

Address

City

State/Province

Zip/Postal

Location Location

If you are human, leave this field blank.

Information and Advocacy Program Intake Form

Client Contact Information

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