Request Services

Submitted by linzy.gressett on Tue, 02/14/2023 - 14:48

If you live in Mississippi and have a disability, the Department of Rehabilitation Services may be able to help you find a job or live at home independently.

To request information regarding services, begin by completing the form below. Once you have submitted this form, someone will contact you to discuss your goals, the nature of your disability, and the services we can provide.

* Denotes a required field.

Service(s): (Check all that apply)

I would like help getting or keeping a job.

I would like help living independently at home.

I would like help with other concerns.

I have the most difficulty:

First Name

Middle Name

Last Name

Gender

Street Address

City

State

Zip Code

County

Phone Number

Email Address

Preferred Method of Contact

Referral Source

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