Client Intake Form

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Alabama Disabilities Advocacy Program (ADAP)

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client intake form

* Indicates required field

Name (the person with the disability) *

First

Last

Email *

Primary Phone *

Work Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

County *

Current Living Arrangements *

If other, please specify. *

Birth Month *

Birth Date *

Birth Year *

Race *

Ethnicity *

Gender Assigned at Birth *

Gender Identity *

Pronouns *

Please specify disability and check all that apply. *

Absence of Extremities Acquired Brain Injury (Stroke, Aneurysm, Tumor, Infection, Alchol/Drug Abuse, Toxic Injury, Metabolic Injury ADD/ADHD AIDS/HIV Positive Autism Autoimmune (Lupus, Thyroid, ALS, etc., Non-AIDS/HIV) Blindness Cancer Cerebral Palsy Deaf-Blind Deafness Diabetes Digestive Disorders (Chronic Pancreatitis, Esophageal Stricture, Fistulae, Chronic Liver, etc.) Epilepsy Genitourinary Conditions (Kidney, Prostate) Hearing Impaired (Not Deaf) Heart and Other Circulatory (Cardiovascular) Intellectual Disability Learning Disability Mental Illness Multiple Sclerosis Muscular Dystrophy Muscular/Skeletal Impairment (Arthritis, Fybromylagia, Osteogenesis Imperfecta, Osteomyelitis, etc.) Neurological Disorders (Brain Tumors, Convulsive Disorders, Parkinson's, etc.) None Orthopedic Impairment (Spinal Cord Injury, Paraplegia, Quadriplegia, Back Problems, etc.) Other Disability (Specify) Other Emotional/Behavior (Specify) Physical/Orthopedic Respiratory Impairment (Emphysema, Asthma, Pulmonary Hypertension, Cystic Fibrosis, etc.) Skin Conditions Speech Impairment Spina Bifida Substance Abuse (Alcohol, Drugs) Tourette Syndrome Traumatic Brain Injury Unknown Visual Impairment (not blind)

Please check all that apply.

If other, please specify. *

Are you contacting us about an education matter? *

Yes No

If you answered yes, please specify the name of the school district here. *

Specify the name of the school here. *

Please select any of the following types of benefits/public supports you receive *

If other, please specify. *

Primary Contact *

First

Last

Email *

Phone Number *

Relationship to the person with the disability *

If other, please specify. *

Address (if different from the person applying for services) *

Line 1

Line 2

City

State

Zip Code

Country

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

Yes No

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? *

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

Submit

*Please note: check your spam and junk folders** for responses from ADAP! Several clients have noted that responses have been filtered automatically to junk or spam, and we want to ensure you see your response from us as quickly as possible.

Home
About Us
Client Assistance Program
Community Issues
Children's Issues
COVID-19 Advocacy Tools You Can Use
Assistance Needed

client intake form

***Please note: check your spam and junk folders for responses from ADAP! Several clients have noted that responses have been filtered automatically to junk or spam, and we want to ensure you see your response from us as quickly as possible.

*Please note: check your spam and junk folders** for responses from ADAP! Several clients have noted that responses have been filtered automatically to junk or spam, and we want to ensure you see your response from us as quickly as possible.