top of page

self-referral
form

HOME > CORE SERVICES > SELF-REFERRAL FORM

If you are interested in any of the DRC services and resources, please complete the self-referral form below and submit. An Independent Living Advocate will follow-up with you within three (3) business days. If you would like to speak to someone directly, you can call the main DRC office number at (712) 255-1065.

​

Please complete the following form as completely as possible.

County you live in (DRC serves only these counties.)
Services requested?

Thank you, we will be in touch soon!

bottom of page