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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: *
 
Name of Contact Person or Person Entering Information: *
 
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, Monument Behavioral Health):

Disability (check all that apply):




















































Do you, or the person needing services, receive:


Are you, or the person needing services, 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?: *
 

* required field