Mission 139 | Advocate Client Intake Form-The Beautifully Huma

Mission 139 | Advocate Client Intake Form

Please fill out this form as best you can so we are able to provide you with the best service.

First name

Last name

Phone Number

Student Information

Please answer the following questions about your child below.

Student's Full Name

Enter Student's Date of Birth

Enter Student's Grade Level & School Name

Does the Student have one of the following:

An Individualized Education Plan (IEP)

A 504 Plan

Neither

Primary Diagnosis/Condition(s): (e.g., Autism, ADHD, Dyslexia, etc.)

What are your main concerns regarding the student’s education or services?

Please describe the nature of your advocacy needs in the next section.

Please select the areas where you are seeking support (check all that apply):

IEP Review/Development

504 Plan Assistance

Attending School Meetings

Dispute Resolution or Mediation

Transition Planning (Post-High School)

Evaluations/Testing Requests

Other

Has the student faced challenges related to:

Behavioral Issues

Academic Performance

Social/Emotional Skills

School Placement

Access to Therapies/Accommodations

Other

Has the student been evaluated within the past 3 years?

Yes

If you answered yes to the question above, what types of evaluations were completed?

Are there any current disputes or issues with the school district?

Yes

If you answered yes to the question above, please explain.

Is there any other information you would like us to know?

Consent and Signature

I acknowledge that the information provided is accurate to the best of my knowledge and will be used solely for the purpose of determining appropriate advocacy services.

Your Signature

Date