Intake Form

You can begin DRNJ's intake process by completing the form below. You can submit the form even if you do not have all the information requested. After you submit your request, a member of DRNJ's intake staff should attempt to contact you within 5 days.


Is another agency/organization or attorney assisting you with this matter presently?

Referred by: (must provide for DVRS cases)

Please complete the next section ONLY if you have a special education issue, otherwise, leave blank.


This form is not compatible with all versions of Internet Explorer. If you experience technical issues submitting this online form, please click here and submit as an email attachment to

NOTE: You must save the attachment before you submit or your information will not transmit.







Disability Rights New Jersey
210 S Broad Street, 3rd Floor
Trenton, New Jersey 08608
1.800.922.7233 (in NJ only) � 1.609.292.9742 (Voice)
1.609.777.0187 (Fax) � 1.609.633.7106 (TTY)
Email Us

Legal Disclaimer