Intake Form - SD Advocacy

221 South Central Ave., Ste. 38
Pierre, SD 57501
(605) 224-8294 (Voice/TTY)
1-800-658-4782 (Voice/TTY)
Fax: (605) 224-5125
Email Us

Field offices:

Rapid City: 605-342-2575
Sioux Falls: 605-361-7438
Yankton: 605-665-5616

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 SDAS can contact you for further information that will determine the level of services SDAS 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 South Dakota Advocacy Services 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): ADD/ADHD AIDS/HIV Autism Auto-Immune Disease Blindness (both eyes) Cancer Cerebral Palsy Deaf/Blind Deafness Diabetes Digestive Disorder Emotional/Behavioral Epilepsy Hearing Impairment (not deaf) Heart/Circulatory Mental Illness Mental Retardation Multiple Sclerosis Muscular Dystrophy Neurological Disorder Physical/Orthopedic Respiratory Disorder Specific Learning Disability Speech Impairment Spina Bifida Substance Abuse Tourette Syndrome Traumatic Brain Injury Visual Impairment (not blind)
Do you receive: Special Education Services SSDI SSI
Are you registered to vote?: *
Reason You Are Contacting South Dakota Advocacy Services
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?: *