Online Contact Form – Disability Law Center

Contact Us

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

"*" indicates required fields

Your Information (Su información)

Your Name (Su nombre)*

First Last

Are you contacting the DLC about yourself, or about someone else? (¿Se está comunicando con el DLC acerca usted u otra persona?)*

Name of the person you are contacting us about (Nombre de la persona sobre la que nos está contactando)*

First Last

Primary disability (Discapacidad primaria)*

Your phone number (Su número de teléfono)

Phone number for person you are contacting us about (Número de teléfono de la persona sobre la que nos contacta)

Your email (Su correo electrónico)*

Email for the person you are contacting us about (Correo electrónico de la persona sobre la que nos contacta)*

Your Zip Code (Su código postal)*

Zip Code of the person you are contacting us about (Código postal de la persona por la que nos está contactando)*

Your date of birth (Su fecha de nacimiento)*

Your gender (Su género)*

Hidden

Your gender (Su género)*

Your preferred pronouns (Su pronombre preferido)

Your ethnicity (Su raza)*

Have you served in the US Military? (Ha servido usted en el ejército de EE. UU.)*

Date of birth of the person you are contacting us about (Fecha de nacimiento de la persona por la que nos está contactando)*

Gender of the person you are contacting us about (Género de la persona sobre la que nos contacta)*

Preferred pronouns of the person you are contacting us about (Pronombre preferido de la persona por la que nos contacta)

Ethnicity of the person you are contacting us about (Raza de la persona por la que nos está contactando)*

Has the person you are contacting us about served in the US Military? (¿La persona por la que nos está contactando ha servido en el ejército de los EE. UU.?)*

Is this a housing issue? (Nos está contactando acerca de un problema de vivienda?)*

Yes (Si)

Type of housing involved (Tipo de vivienda involucrada)*

Please explain your question(s) and/or concern(s) below (Explique su (s) pregunta (s) y / o inquietud (s) a continuación)*

Additional Information (Optional) (Información Adicional (Opcional))

Your Address (Su dirección)

We ask for your address in case you would like more information sent to you about your request or the services offered by the DLC. (Le pedimos tu dirección en caso de que quiera que le enviemos más información sobre su solicitud o los servicios que ofrece el DLC.)

Street Address Address Line 2 City State ZIP Code

Address of the person you are contacting us about

Street Address Address Line 2 City State ZIP Code

Do you currently receive Social Security? (Usted recibe actualmente beneficios del Seguro Social?)

We ask if someone is receiving Social Security because it helps us determine what funding is available to help. (Hacernos saber cómo se enteró del DLC nos ayuda a mejorar la eficacia con la que nos comunicamos con la comunidad.)

Does the person you are contacting us about currently receive Social Security?

We ask if someone is receiving Social Security because it helps us determine what funding is available to help.

How did you learn about the Disability Law Center? (Como se entero acerca del Disability Law Center?)

Letting us know how you learned about the DLC helps us improve how effectively we communicate with the community. (Hacernos saber cómo se enteró del DLC nos ayuda a mejorar la eficacia con la que nos comunicamos con la comunidad.)

From what attorney did you hear about the DLC?

From what event did you learn about the DLC? (¿En qué evento escuchó sobre el DLC?)

From what other agency/organization did you learn about the DLC? (¿En que agencia / organización escuchó sobre el DLC?)

From what publication did you learn about the DLC? (¿En qué publicación se enteró sobre el DLC?)

From what radio/television/newspaper did you learn about the DLC? (¿En qué radio / canal de televisión / periódico aprendió sobre el DLC?)

Please briefly describe more about where you learned about the DLC? (Describa brevemente más acerca de dónde aprendió sobre el DLC.)

Phone

This field is for validation purposes and should be left unchanged.