Provider Intake Referral Form

Alabama Disabilities Advocacy Program

PROVIDER INTAKE REFERRAL FORM

The Alabama Disabilities Advocacy Program (ADAP) provides FREE legal services to Alabamians with disabilities to protect their civil rights. We help with issues like special education, Medicaid, community integration, assistive technology, and ADA violations.

By completing and signing this intake referral form, you are:

Authorizing the provider listed below to share it with ADAP.
Authorizing ADAP to contact you so we can discuss your child’s disability-related legal rights concerns with you to see what, if any, help we can offer.

By completing and signing this intake referral form, you are NOT:

Entering into an attorney-client relationship with ADAP. ADAP will not become your attorney unless and until we provide you with a written agreement that describes the scope of the services that we will provide.

Provider Information

* Indicates required field

Provider Name *

Contact Person *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Client Information

Client Name *

First

Last

Date of Birth *

Parent/Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Phone Number *

Email *

Concerns / Reason for Referral *

Parent / Guardian Signature *

Submit

Provider: Please submit the completed form, print, sign and email it to adap@adap.ua.edu
or print, sign and fax to ADAP at (205) 348-3909. Questions? Contact ADAP at (205) 348-4928