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Alabama Disabilities Advocacy Program (ADAP)
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*
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
*
I rent an apartment
I own my own home
I live with a relative or friend
I live in a nursing home
I live in a rehabilitation facility
Other (Please Specify)
If other, please specify.
*
Birth Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Birth Date
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
*
Race
*
Black/African-American
American Indian or Alaska Native
Hispanic/Latinx
Native Hawaiian or Pacific Islander
White
Asian
Prefer Not to Answer
Ethnicity
*
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
Gender Identity
*
Agender
Bigender
Female
Gender fluid
Genderqueer
Male
Other/prefer not to answer
Transgender F/M
Transgender M/F
Prefer Not to Answer
Pronouns
*
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Prefer Not to Answer
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
*
All Kids (State CHIP Program)
Eligible for waiver supports (ID, E&D, etc) but on waiting list
Medicaid
Medicaid & SSI
Medicare & SSDI
None
Private Insurance
Receiving Alabama Community Transition (ACT) waiver
Receiving Elderly & Disabled (E&D) waiver
Receiving HIV/AIDS waiver
Receiving Intellectual Disabilities (ID) waiver
Receiving Living at Home waiver
Receiving State of Alabama Independent Living waiver
Receiving Technology Assisted waiver for Adults
SSDI
SSI
TRICARE
Other (Specify)
If other, please specify.
*
Primary Contact
*
First
Last
Email
*
Phone Number
*
Relationship to the person with the disability
*
Spouse
Parent
Child
Sibling
Other relative
Friend
Other
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?
*
Is there a deadline associated with the issue you're contacting us about (ex., court deadline, termination of benefits)?
*
Yes
No
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
See more about
eligibility criteria
and current
goals and priorities
.
***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
ADAP Services
ADAP Staff
Mission & Values
Goals & Priorities
ADAP Eligibility Requirements
Programming
Career and Clerkship Opportunities
ADAP Disclaimer
ADAP Awards
>
Jeff Ridgeway
Ricky Wyatt
Client Assistance Program
ADAP Advisory Council
PADD Advisory Council
PAIMI Advisory Council
Community Issues
Abuse/Neglect
Assistive Technology
Employment
Community Waiver Program
HIV/AIDS
Mental Health
Social Security
Traumatic Brain Injury (TBI)
Veterans
Voting
>
Vote for Access
Guardianship
Children's Issues
Bullying
Children's Mental Health
Foster Care
Juvenile Justice
Protecting Youth in Facilities
Special Education
Transitioning to Adulthood
Assistance Needed
COVID-19 Advocacy Tools You Can Use
>
Healthcare
Safety in Community / Facility
Special Education (K-12 and Post-Secondary)
Transportation and Housing
Voting
Resources
>
Client Intake Form
ADAP General Contact Form
ADAP Publications
ADAP Federal Partners
Grievance Procedure
Grievance Form
Satisfaction Survey
Office Location
Request Education / Training Presentation
Request Exhibit
Request a Publication
Special Education Bulk Book Order Form
Report Broken Links or Other Website Issues