ADAP Client Intake Form

Client Information

Name (the person with the disability)

First Name

Last Name

Primary Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

County

Primary Contact

First Name

Last Name

Primary Phone

Relationship to the person with the disability

If other, please specify

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

I would like to be added to ADAP's mailing list

Further Questions

Describe the problem that prompted you to contact ADAP

What would you like ADAP to assist you with?

What steps have you taken to resolve this issue on your own?

Is there a deadline associated with the issue you're contacting us about (ex., court deadline, termination of benefits)?

If yes, what is the date of the deadline?

Please describe any accommodations you may need to help with the intake process

In submitting this intake form, I understand the following (Please check all):

This intake form does not create an attorney-client relationship between me and ADAP

In accepting this intake, ADAP is not agreeing to represent me in any legal matter

ADAP is not responsible for ensuring that any identified requirement or deadline is met

ADAP will evaluate my request for legal help in compliance with its eligibility criteria and current goals and priorities

ADAP will contact me to set up a telephone intake appointment to conduct a full intake regarding my concern. (Please note that it may take a few days to contact you)

Submit

Client Intake Form

Client Information

Name (the person with the disability)

Address

Client Questions

Primary Contact

Address

Further Questions

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