Request Services

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:

CONTACT INFORMATION

*First Name

Middle Name

*Last Name

Gender

Street Address

City

State

Zip

*County

*Phone

*Preferred Method of Contact

Referral Source

Clear Request