Alabama Disabilities Advocacy Program
PROVIDER INTAKE REFERRAL FORM
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:
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.
- 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
Provider: ____________________________________________________________________________________________________________________________
Contact Person: ______________________________________________________________________________________________________________________
Address: _______________________________________________ City: _______________________________________ Zip: _____________________________
Phone: ______________________________________________________ Email: _________________________________________________________________
Contact Person: ______________________________________________________________________________________________________________________
Address: _______________________________________________ City: _______________________________________ Zip: _____________________________
Phone: ______________________________________________________ Email: _________________________________________________________________
Client Information
Child's Name: ________________________________________________________________________________________________________________________
Date of Birth: ____________________________________________
Parent / Guardian Name: _______________________________________________________________________________________________________________
Parent / Guardian Signature: ____________________________________________________________________________________________________________
Address: ________________________________________________ City: ______________________________________ Zip: _____________________________
Preferred Phone: _____________________________________________ Email: __________________________________________________________________
Concerns / Reason for referral: _________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date of Birth: ____________________________________________
Parent / Guardian Name: _______________________________________________________________________________________________________________
Parent / Guardian Signature: ____________________________________________________________________________________________________________
Address: ________________________________________________ City: ______________________________________ Zip: _____________________________
Preferred Phone: _____________________________________________ Email: __________________________________________________________________
Concerns / Reason for referral: _________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Provider: please print and fax the signed, completed form to (205) 348-3909 or email it to adap@adap.ua.edu
Questions? Contact ADAP at (205) 348-4928
Questions? Contact ADAP at (205) 348-4928