Disability Rights Maine (en-US)

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.

First Name

Last Name

Address

City/State

Zip Code

Home Phone

Work Phone

Cell Phone

I am contacting DRM for MyselfMy minor childMy adult childMy spouse/significant otherSomeone else

Date of Birth

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.

Name of the person you are contacting us about

If you are not seeking assistance for yourself, who is the person you would like DRM to assist?

Are you this person's legal guardian? NoYes

Who is your complaint against?

Name of individual, employer, service provider, etc.

Your Story

Please tell us about the issue that you are looking for help with, including how you would like to see this situation resolved.

Have you received a COVID-19 vaccine shot?

DRM is working to ensure that individuals with disabilities have access to the COVID-19 vaccine, including assistance with scheduling appointments and arranging transportation to vaccine clinics. Please answer the following questions to let us know if you have received the vaccine, need assistance with accessing the vaccine, or would like information about the safety and importance of COVID-19 vaccines.

YesNoDecline to AnswerMedically ContraindicatedNot Applicable - I do not have a disabilityNot Applicable - I am seeking help for my child who is not eligible for the vaccine

Do you need a second shot? YesNo

Have you received your second shot? YesNo

Do you need assistance with getting a vaccine shot - either your first or second? NoYes, I need assistance with scheduled an appointmentYes, I need assistance with arranging transportationYes, I need assistance with both scheduling and transportationI need other assistance

Do you plan to get the vaccine? YesNo

If you are undecided or not planning to get a vaccine shot, can DRM send you some information about safety and importance of receiving the COVID vaccine? YesNo