Home > Services > Intake Form Intake Form You may complete and submit this form to request services for an issue directly related to a disability. A current phone number is required so DRSD can contact you for further information that will determine the level of services DRSD can provide. If you are not comfortable with completing this form or have difficulty completing this form, please contact our office at 1-800-658-4782 and ask for an Intake Specialist. If you are contacting Disability Rights South Dakota about an individual with a disability other than yourself, we will ask you to have the individual contact us directly, unless you are: The parent of a minor child The guardian, or Other authorized representative I understand that by completing and submitting this Intake Form, I am applying for services from DRSD. Submitting this Intake Form does not create an attorney-client relationship. Disability Rights South Dakota has a centralized intake process. All people seeking to become clients of this agency must first go through the intake process. That process can be initiated by submitting this Intake Form or by contacting the Intake Team at 1-800-658-4782. The Intake Team makes decisions about who the agency will assist or represent based on eligibility, program priorities, and available resources. Disability Rights South Dakota will keep the information in this Intake/Application confidential. If DRSD agrees to assist or provide legal representation to you, DRSD will send you a Letter of Understanding and/or Representation Agreement to sign. Name of Person Needing Services: * RequiredName of Contact Person or Person Entering Information: * RequiredMailing Address:City:State:Zip Code:Telephone / Contact Number: * RequiredAlternate Telephone / Contact Number:E-Mail Address: * RequiredDate of Birth (xx/xx/xxxx):*Disclaimer* Our funders have asked us to collect some demographic information, it's optional and will only be used to help ensure we are being inclusive and equitable. You can select "prefer not to answer" any questions about Sexual Orientation or Gender Identity. Making this selection will not have any impact on our determination on providing services or any aspect of our services should your issue be assigned to advocacy staff.Sexual Orientation: * Strait (not lesbian or gay) Bi-Sexual Lesbian or Gay Two-heart Prefer not to answer Other (I use a different term) Unknown RequiredGender Identity: * Female Male Non-Binary Not Selected Other Transgender Two-Spirit Prefer not to answer RequiredEthnicity:Veteran Status: * Yes No RequiredLiving Arrangements: * Independent Living Group Home Nursing Home Live with Parents Homeless Jail / Prison / Detention Center Public Institution or Hospital Private Institution or Hospital RequiredAre you or the person you are calling about in a facility?: * Yes No RequiredIf Yes, which one? (HSC, Avera Behavioral Health, Monument Behavioral Health):Disability (check all that apply): Absence of Extremities Acquired Brain Injury ADD ADD/ADHD ADHD AIDS/HIV All Other Disabilities Anxiety Disorder Arthritis or Rheumatism Asperger's Syndrome Autism Auto-Immune (non-AIDS/HIV) Bi-polar Blindness (both eyes) Cancer Cerebral Palsy Deaf/Blind Deafness Depression Diabetes Digestive Disorders Down Syndrome Dyslexia Epilepsy Fibromyalgia Genitourinary Conditions Hard of Hearing (not deaf) Heart and Other Circulatory Conditions Intellectual Disability Mental Illness Multiple Sclerosis Muscular Dystrophy Muscular/Skeletal Impairment Neurological Disorders/Impairments Not Selected Orthopedic/Physical Impairments Other Emotional/Behavioral Other Intellectual Other Mental Illness Other Physical/Orthopedic Personality Disorders Pervasive Developmental Delays PTSD Respiratory Disorders/Impairment Schizophrenia Skin Conditions Specific Learning Disabilities (SLD) Speech Impairments Spina Bifida Substance Abuse Tourette Syndrome Traumatic Brain Injury (TBI) Visual Impairment (not blind) Do you, or the person needing services, receive: Special Education Services SSDI SSI Are you, or the person needing services, registered to vote?: * Yes No RequiredReason You Are Contacting Disability Rights South Dakota -Please describe the problem and how it is related to the person's disability and when it happened: Describe any deadlines you have. You are responsible for all deadlines: Name of agency assisting you if any:Is there an attorney assisting you with your issue?: * Yes No Required* required field