Advocacy Intake Form

Name * Required

Email * Required

Phone * Required

Best times to discuss services

mornings

lunchtime

evenings

weekends

What is your relationship to the child/student?

legal guardian

family service provider

teacher/educator

medical provider

self

other

Family, Organization or Company name

Briefly describe the mission or service provided, or give a website

Services requested

Check all that may apply

Advocacy

Coaching

Early Childhood Planning or Screening

Education Consulting

Equity Review

Expert Witness

Education Plan Check-Up (eg. IEP, 504, IFSP)

Meeting support

Observation

Parent Education

Progress Monitoring

Record Review

Other

Child's first or last name or initials * Required

Child's grade * Required

Child's age * Required

Child birthdate * Required

Disability or Difference * Required

Briefly describe the child's /children's need, disability or difference

Enter any medical or educational diagnosis * Required

Briefly note any related services, therapies, or providers involved in the child's care * Required

Enter n/a if not pertinent

School District, County or City * Required

School Name

Enter date of last school meeting (or approximate)

Enter date of upcoming school meeting (or approximate)

Briefly describe your overall current concerns regarding your child's education. * Required

Briefly note any parenting concerns. * Required

Referral Source * Required

How did you hear about us? Indicate website, person/organization name, event or other

Financial Expense

Advocacy is a worthy expense at some point, if not for the duration across the education span. For families with significant financial need in Montgomery County or Prince George's County, Maryland, who receive federal, state, or county financial aid program assistance to attend certain schools, free or reduced advocacy may be available. Families should contact www.SEEUSadvocacy.org to apply for eligibility.