Get Help

You can request assistance from Kentucky Protection & Advocacy by submitting the form below. If you provide an email address, an email confirmation that your request was received will be sent to you.

Someone will respond to your request within 3 business days.

Field GroupContact

Individual's Information

---

First Name *PERSON WHO NEEDS ASSISTANCE

Last Name

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

County

Is this person deaf or hard of hearing?YesNo

If an interpreter is needed what language?

Person's disability

Date of Birth *

Please select the person needing assistance date of birth.

Living arrangementPlease provide person needing assistance current living arrangement.

If person is over 18, does he/she have a guardian? *YesNo

Is this person a recipient of SSI/SSDI?YesNo

If this person is over 18, is he/she registered to vote?YesNo

If this person is over 18, is he/she a veteran?YesNo

Phone number *

Email Address *

How should we contact you? *phoneemailtextotherPreferred method of contact

If other, enter method of contact preferred below.

GenderMaleFemalePrefer not to say

RaceAmerican Indian/Alaska NativeAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhite

EthnicityHispanic/LatinoNot Hispanic/Latino

If completing on behalf of another person, what is your name: *

What is your relation to this person? *

If the reason you are making contact involves a school issue, provide the name of the school:

How did you hear about P&A?

How can we help you?

Submit

Please do not fill in this field.