Application

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Application

3. Application

Complete an online application. Faster than calling us.*

4. Confirmation

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Online Application for Help

Step 1 of 4

25%

Complete this application online or call us

Completing this application is typically faster than our average phone wait times.
If you prefer to call, DRNC's intake phone number is: 919-856-2195.

Office hours

Our intake hours are Monday through Thursday from 10 am to 4 pm. If you need an accommodation, please call our office to make your request.

Report abuse or neglect in facilities

DRNC's Abuse and Neglect Hotline: 919-856-2195 and select option 7.

Your Name(Required)

First Name Last Name

Your Phone(Required)

What is the best day / time to reach you?(Required)

Please provide a few options.

Applicant Type(Required)

I am a person with a disability, and I am contacting Disability Rights NC about a problem I am having.

I am the legal guardian of a person with a disability, and I am contacting Disability Rights NC about a problem facing the person for whom I am the guardian.

I am reporting an allegation of abuse, neglect, or exploitation of a person with a disability.

Other

Please describe.(Required)

We are only able to help persons with a disability or persons with legal authority to make decisions on behalf of a person with a disability. We cannot help you if you are contacting us regarding a person with a disability and you do not have legal authority to make decisions on that person’s behalf. Please have the person with a disability or their legal guardian contact us. If you are a professional working in a disability field and are contacting us for information or technical assistance, please continue to fill out this form.

Do you need any accommodations to conduct an intake?(Required)

Yes

*We take reports of abuse or neglect of a person with a disability from anyone. We are required by federal law to keep the name of the person who is reporting confidential.*

I need help with:(Required)

If you do not see the issue you need help with, it is because it is not an area practiced by DRNC attorneys. Issues we cannot help with include: SSI/SSDI eligibility, custody issues, criminal law, and personal injury. See the full list here.

Abuse/neglect of children in school

Abuse/neglect/exploitation/rights violations of adults or children by service providers

Restriction of rights by guardians

Barriers to community access

Denial of Medicaid services needed to live in the community

Employment discrimination

Exclusion from school

Housing discrimination

NC jails and prisons - mental health care or failure to accommodate disabilities

SSA Representative Payee exploitation

Voting challenges

Other

Please describe the problem you are having.(Required)

How have you tried to resolve your problem?(Required)

Do you have any deadlines?(Required)

Yes

I don't know

Describe any deadlines you have.(Required)

(If you have a deadline to appeal a decision, you should appeal that decision before the deadline. Do not wait for Disability Rights NC to contact you before submitting an appeal.)

What are you hoping DRNC can help you with?(Required)

Is there anything else you would like us to know?(Required)

How did you hear about Disability Rights NC?(Required)

Other(Required)

Contact information

Please provide your contact information:

Your Address(Required)

Street Address City State ZIP Code

Your County(Required)

Your Email(Required)

What is the best time/day to reach you?(Required)

If you are contacting us about someone with a disability, provide their name.(Required)

First Last

Their Address(Required)

Street Address City State ZIP Code

Their County(Required)

Their Phone

Demographic Information

We ask for this information as part of our grant requirements. We need to report the demographics of the people we help. This information is not shared or used for any other reason.

Please complete all questions below for the person with the disability

Birthdate(Required)

Sex(Required)

Please provide your sex as stated on your birth certificate.

Male

Female

Race(Required)

Please provide your race

American Indian / Alaskan Native

Asian

Black/African American

Native Hawaiian/ Other Pacific Islander

White/Caucasian

Two or more races

Race Unknown

Prefer not to answer

Ethnicity(Required)

Please provide your ethnicity

Ethnicity Unknown

Hispanic/Latino

Not Hispanic/Latino

Prefer not to answer

Diagnosis / Disability (optional)

What is your annual household income?

This can be an estimation. This information is required for reporting to support the grants that help us continue to provide help for our communities.

$0 - $10,000

$10, 001 - $20,000

$20,001 - $30,000

$30,001 - $40,000

$40,001 - $50,000

$50,001 - $60,000

$60,001 - $100,000

More than $100,000

Number of people in your household?(Required)

Please enter a number from 1 to 100.

Add me to DRNC's mailing list? (Optional)

Yes, add me

Email(Required)

Report abuse or neglect

To report abuse or neglect in a facility, call 919-856-2195 and select option 7.

Medicaid / SSI / SSDI

Get help with Medicaid / SSI / SSDI eligibility, applications, benefits, denials or appeals.

View Resource

Application

Online Application for Help

Complete this application online or call us

Office hours

Report abuse or neglect in facilities

Contact information

Demographic Information

Report abuse or neglect

Medicaid / SSI / SSDI

Languages

Automatic

Resources

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