Disability Rights Legal Center

Full Name (First, Last):

Address:

City:

State: Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

County:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Preferred method of contact (check one): Home Cell Work E-mail

How did you hear about the CLRC:

Person with Cancer

(If you are contacting the CLRC on behalf of someone else)

Full Name (First, Last):

Address (if different from above):

City:

State: Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

Note: appropriate legal information and resources will be collected based on the city, county, and state of the person with cancer. Please indicate if another location should be used.

Gender (check one): Male Female

Age:

Note: Resources are often based on income level and providing accurate information will help us to provide resources that are the best match for you.

Number of people in household:

Type of cancer:

Can we use this anonymous statistical information for research purposes (check one): Yes No

Reminder: Everything disclosed is confidential. Even if you give us permission to use your statistical information for research purposes, none of your personally identifying information (name, address, phone, etc.) will be disclosed to anyone outside of the CLRC.

Are you represented by an attorney in this matter (check one): Yes No

Note: the CLRC is limited in the resources that we can provide if you have an attorney retained on this matter.

Intake Information

Specific intake questions:

If you are contacting us regarding an employment issue:

Name of employer (for a conflicts check):

Total number of employees:

Your length of employment:

Is there a company policy/manual that may apply to the situation (check one): Yes No

Are you a member of union a (check one): Yes No

Is your employer a state governmental body or agency (check one): Yes No

Is your employer a federal governmental body or agency (check one): Yes No

If you are contacting us regarding a health insurance issue:

Name of insurance company (for a conflicts check):

If you are contacting us regarding a disability issue:

Are you receiving any of the following disability benefits? (Press Ctrl and then click on all the options that apply): No state disability insurance (SDI) Supplemental Security Income (SSI) Social Security Disability Insurance (SSDI) Private Long Term Disability Private Short Term Disability Insurance

Did you want to apply or appeal for any of the following disability benefits? (Press Ctrl and then click on all the options that apply): No state disability insurance (SDI) Supplemental Security Income (SSI) Social Security Disability Insurance (SSDI) Private Long Term Disability Private Short Term Disability Insurance