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Request Information
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
Name: *
 
Mailing Address:
City:
State:
Zip Code:
Telephone / Contact Number: *
 
Alternate Telephone / Contact Number:
E-Mail Address: *
 
Date of Birth (xx/xx/xxxx):
Gender:
Ethnicity:
Veteran Status: *
 
Living Arrangements: *
 
Are you or the person you are calling about in a facility?: *
 
If Yes, which one?
(HSC, Avera Behavioral Health, Regional West):

Disability (check all that apply):




























Do you receive:


Are you registered to vote?: *
 

Reason 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?: *
 

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This site offers legal information from a variety of sources. South Dakota Advocacy Services makes every effort to ensure the accuracy of the information. This site is not intended to provide legal advice - the application of the law to your individual circumstances. For legal advice, you should consult an attorney.