Online Intake Form

Use this form to ask the Disability Rights Center of Kansas to help you with a problem. Someone from DRC Kansas will respond as soon as possible. Please do not include sensitive information that should be kept private, such as your social security number.

Filling out this form is not an indication of an attorney/client relationship and does not guarantee legal representation.

Are you filling out this form for yourself or for someone else?

Do you, or the person for whom you are filling out this form, have a disability?

First Name ■

Last Name ■

Address ■

Address 2

City ■

State ■

Zip Code ■

Your E-Mail Address ■

Phone Number ■

Gender

Do you, or the person for whom you are filling out this form, have any of the following?

Please Select One or More

None of these

Guardian

Durable Power of Attorney

Payee

Not Sure

Please describe why you are contacting DRC ■

Please be aware there are certain types of cases DRC cannot work on.

What are you asking DRC staff to do about the above issue? ■