Request Child and Family Advocacy

Areas of Assistance

Our Arc intake specialist will contact you to go over the following and discuss:

Name

We assist people with a known or suspected intellectual/developmental disabilities (IDD)

An advocate will reach out to you to schedule a free consultation to discuss questions and concerns

You may need to provide necessary documents prior to the consultation appointment. (Ex: IEP/504, BIP, evaluations, etc.)

Please note, advocacy services may be an option if the person meets intake and eligibility requirements.

Person Making the Request:

Date

Your Name

Relationship with youth

Phone number

Name of youth

Age of youth

Grade of youth

School district

School of Attendance

Are there concerns about attendance?

What type of disability does the Youth have? Check all that apply. May check more than one box.

What do you need help with? ? Check all that apply. May check more than one box.

How do you want to be contacted to schedule the consultation

When are you best available during the work week for the consultation (Monday through Friday, 8:00 am to 4:00 pm.)

How would you like to meet with the advocate

Acceptance for Professional

Professionals must have permission from the guardian to submit this request.

Your Name

Your phone number

Your email address

Relationship with youth

Name of guardian

Phone number of guardian

Email address of guardian

Name of youth

Age of youth

Grade of youth

School district

School of attendance

What type of disability does the Youth have? Check all that apply. May check more than one box.

What do you need help with? ? Check all that apply. May check more than one box.

Family's preferred method of contact

Best available time during the work week for the consultation (Mon - Fri, 8:00 am to 4:00 pm.)

How would you like to meet with the advocate?

As a professional, you acknowledge that you have permission from the parent to make this referral?

I do.