Online Intake Form

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Please complete as much information as possible. While you are not required to submit a phone number, doing so will ensure that your intake request is handled the most effectively.

If you have any difficulties using this form, please feel free to contact us via phone at (800) 342-0823 or via TDD at (800) 346-4127.

Items with an asterisk (*) are required.
Information Related to the Person with a Disability















Enter "none@none.com" if you don't have an email.




Person Completing Form on Behalf of Person with a Disability
If you are contacting Disability Rights Florida about an individual with a disability, and you are the parent or guardian, or the individual is unable to make contact due to his/her disability, you are required to complete the following information about yourself.














Important: Please confirm you have entered correct information BEFORE clicking the "Next Page" button.

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Living Arrangement




Reason You Are Contacting Disability Rights Florida










Important: Please confirm you have entered correct information BEFORE clicking the "Next Page" button.

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Miscellaneous Questions






Upload Documents
Use the fields below to send us any relevant documents regarding the reason you are contacting us today. (Only accepts PDF, .doc, .docx, .rtf and .txt documents no larger than 2 Mb.)




By submitting this I certify the above to be true.