IPAS: Online Intake Form

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IPAS > Contact Us > Online Intake Form Online Intake Form

Complete this form if you have a disability rights question or problem and wish to be contacted by an IPAS advocate.

Please complete as much information as possible. If you are not comfortable with completing this form or have difficulty completing this form, please contact our office at (800) 622-4845 or via TDD at (800) 838-1131 and ask for an Intake Specialist.

If you are contacting Indiana Protection and 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 court appointed legal guardian

I need help with my own disability rights issue.

Please provide the following information:

First Name:

Last Name:

Date of Birth:

Type of disability:

Mailing Address:

City:

State:

County:

Zip code:

Phone #:

Email address:

What is your preferred way that we use to contact you? Email, Telephone, Mail, Relay Indiana:

What day and time would be best for IPAS staff to reach you during Monday to Friday (8 am to 4:30Pm):

Please describe any accommodations you need to request IPAS help.

Please briefly describe your disability rights question or problem (including when it happened) and/or reason for contacting Indiana Protection and Advocacy Services.

Describe any deadlines or time lines you have. You are responsible for all those deadlines and any time lines.

What steps have been taken to resolve the issue?:

Is there anyone who is working with you on this matter?:

I need help with a disability rights issue which concerns my minor child or an adult for whom I am the court appointed guardian.

What is the full name of the individual with a disability?:

What is your relationship to the individual with a disability?:

Why are you contacting IPAS instead of the individual doing so?:

Your full name::

Address:

City:

State:

Zip code:

Phone #:

Email address:

What day and time would be best for IPAS staff to reach you during Monday to Friday (8 am to 4:30Pm):

What is your preferred way that we use to contact you?:

Please briefly describe the problem that is related to the person's disability (including when it happened) and/or reason for contacting Indiana Protection and Advocacy Services.:

Describe any deadlines or time lines you have. You are responsible for all those deadlines and any time lines.:

What steps have been taken to resolve the issue?:

Is there anyone who is working with you on this matter? If so who?:

Notice: Please be advised that:

IPAS is not an emergency service.
IPAS has not promised to represent you or to look into your concern at this time.
IPAS has made no guarantees or representations regarding a successful outcome of the services it provides.
IPAS has agreed only to contact to assess your request for assistance.
IPAS staff will attempt to contact you within two business days following receipt of this form.
Should IPAS agree to look further into your concern, even then IPAS will not make a decision whether or not to represent you until the research is completed to IPAS’ satisfaction.