Online Intake Form


If you are seeking advocacy/legal assistance on behalf of yourself or someone else, please complete DRM's Online Intake Form. Our intake staff will review your request for assistance to determine whether we may be able to assist. If we need additional information in order to make this assessment, someone will contact you to set up a telephone intake appointment.

When completing this form, please be careful not to share sensitive information, such as your Social Security Number.

Please provide your date of birth, or the date of birth for the person you are contacting us about. If you do not know their date of birth, you may leave this field blank.
If you are not seeking assistance for yourself, who is the person you would like DRM to assist?
Name of individual, employer, service provider, etc.
Please tell us about the issue that you are looking for help with, including how you would like to see this situation resolved.