Disability Rights Ohio - Staff Contact Form

Disability Rights Ohio Online Intake Form

This form is intended to be completed by people over the age of 13. Please complete the form below and click “Submit” when you are finished. A DRO staff member will contact you as soon as possible.

Disability Rights Ohio is required to collect demographic information for federal grant reporting purposes. DRO must obtain data to ensure services are available across the state to diverse populations. If you do not want to share this information, you can decline to answer those questions. No matter how you answer, this will not impact your eligibility for services.

Due to limited resources, DRO cannot fulfill every request for assistance. Still, DRO tries to provide everyone with information and referrals, even when we cannot provide direct representation.

Please do NOT include sensitive information on this form such as Social Security Numbers or Medicaid/Medicare numbers.

* indicates required information

Recipient:

Kara Hinton

Person with the disability requiring assistance:

* First Name:

Middle Initial:

* Last Name:

Street Address:

Address Line 2:

City:

County:

State:

Zip Code:

Phone Number:

Email Address:

Race (optional):

Ethnicity (optional):

Gender:

Date of Birth (if known):

* Disability:

If disability is mental illness, please state diagnosis

* Problem Description:

* What service is being requested of DRO?

Are there any upcoming deadlines, hearings, or meetings related to this issue?YesNo

If yes, Date/Time:

Please note that you will remain responsible for meeting any upcoming deadlines or attending any hearings.

If this issue is education-related, please check this box:

School District:

Is there currently an IEP?YesNo

If this issue is related to post-secondary education, please check here:

If you have applied for or are currently receiving Vocational Rehabilitation services from Opportunities for Ohioans with Disabilities, please check this box:

Name of the person filling out this request, if different from person with disability:

If you are the person with a disability, please check this box:

First Name:

Middle Initial:

Last Name:

Street Address:

Address Line 2:

City:

County:

State:

Zip Code:

Phone Number:

Email Address:

What is your relationship to the person with a disability?

Additional Contact Name:

Additional Contact Phone Number:

Additional Contact Relationship to Person With a Disability:

By submitting this form, you agree and understand that that submitting an intake request does not create an attorney client relationship and does not guarantee legal representation from Disability Rights Ohio.

Internal Comments:

For internal use only

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