Advocacy Request Form

Quality Trust for Individuals with Disabilities

ADVOCACY REQUEST/INTAKE FORM

Date of Request:__________

Individual's Name: __________________________
DOB:________Sex:______Race:______SS#:__________________
Home Address: __________________________________________
City:______________________________State:______Zip:________
Phone Number: H________________ W____________Ward:______
Reason for Advocacy________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Referred by:_______________________________________________
Address:__________________________________________________
Relation to Applicant:________________________________________
Contact number:____________________________________________
Advocacy referrals can be made by the two ways listed below

Mail to: Quality Trust for Individuals with Disabilities

5335 Wisconsin Avenue, NW, Suite 825

Washington, DC 20015

Fax to: 202-448-1451

Referred to:___________ Date: ____________________

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© Copyright 2002-2003 Quality Trust For Individuals With Disabilities, in Washington, DC, Inc. All rights reserved.

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