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323-892-2225 (VP)
323-478-8000 (Voice/TTY)

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About Us
Get Involved
Services
Resources
Events & Workshops
- American Sign Language Classes
Contact

Request Interpreter

Language

About Us
Get Involved
Services
Resources
Events & Workshops
- American Sign Language Classes
Contact

About Us
Get Involved
Services
Resources
Events & Workshops
- American Sign Language Classes
Contact

Intake Form

Our services hours have been updated. Our offices are open for in-person services on Mondays, Tuesdays & Thursdays. On Wednesdays & Fridays, services provided by VP and email only.

Step 1 of 3

33%

Name(Required)

First Name Last Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number

Email(Required)

Contact Preference(Required)

VP

Text/SMS

Voice

Enter VP Number

Enter Text/SMS Number

Enter Voice Number

Gender:(Required)

Male

Female

Transgender

Non-Binary

Are you:(Required)

Deaf

Hard of Hearing

Late Deafened

DeafBlind

Hearing

Optional: This information is collected for statistical purpose only and is anonymous.

Race:

White

Black/African American

Asian/Asian American

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Multi

Other

Hispanic/Latino

Immigration Status:

US Citizen

Lawful Permanent Resident/Green Card Holder (LPR)

Work Permit (Red Card)

Undocumented

Age:

0-5

6-11

12-17

18-34

35-54

55+

Female Headed Household

Yes

No

Number of Persons in Household

Children (Under 18)

Adults (18+)

Additional Information

Confidentiality and Informed Consent:

All consumer information is kept strictly confidential. I understand that selected information may be released without my name as data for mandatory government reports.

Please add me to the Email list for GLAD events and information.

Yes

No

Intake Process

VP Intake

Email Intake

Phone Intake

Consumer Signature(Required)

Email

This field is for validation purposes and should be left unchanged.

Contact Us

323-892-2225 (VP)
323-478-8000 (Voice/TTY)
2222 Laverna Ave
Los Angeles, CA 90041
Click here for all office locations.
Have complaint or concern? Click here

Hours

Monday - Friday
8:30 AM - 12:00 PM
1:00 PM - 5:00 PM
Click here for holiday closures.

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