We operate with self-referrals, which means if you'd like to work with us to start living independently, you can refer yourself to the Disability Empowerment Center.  

If you would like to begin working with us, you can call our office at 717-394-1890 or you can fill in this form.

All information that you provide is secure and only available to DEC personnel.  The more information provided on this form, the faster we can begin working together!

Please tell us if you are scheduling an appointment for yourself or for someone else.

If you are scheduling for yourself, please skip to the "Consumer Information" section.
If you are scheduling for someone else, please fill in your name and contact information in these boxes and fill in the rest of the form with their information.

Consumer Information:

Help Text

Disability Information:

Please describe your primary disability.

Please describe your secondary disability, if applicable.

Meeting Information:

Please provide us with your preferred meeting day(s).  Choose as many as you prefer.  This will help us schedule your meeting more quickly.

Please provide us with your preferred meeting time(s).  Please choose all that apply.  This will help us to schedule your first meeting more quickly.