Hilary's Wheels of Hope Student Intake Form

Welcome to Hilary’s Wheels of Hope

Hilary’s Wheels of Hope provides educational advocacy and transition-focused support for students with disabilities. Our goal is to help students better understand their educational rights, build self-advocacy skills, and prepare for successful transitions into postsecondary education, employment, and independent living.

We work alongside students and families to support:

Understanding school-based accommodations and supports (such as IEPs and 504 Plans)
Developing self-advocacy and communication skills
Preparing for transitions leading to greater independence
Navigating personal care considerations as they relate to education and independence

This intake form helps us learn more about the student’s educational environment, support needs, and goals. The information provided allows us to offer individualized guidance and transition planning support. Some questions address academic accommodations, personal care routines, and care-related supports, as these areas can impact a student’s access to education and independence.

Hilary’s Wheels of Hope does not replace school services, medical providers, or personal care agencies. Instead, we focus on education, advocacy, planning, and skill-building to support the student’s success.

All information shared will be kept confidential and used solely for the purpose of providing services through Hilary’s Wheels of Hope.

Hilary's Wheels of Hope

Student Intake Form (High School & College Students)
Section 1 - General Information

The purpose of this intake form is to help us understand your background, educational goals, and support needs, so we can provide services that are appropriate, respectful, and effective. Please answer to the best of your ability. You may skip questions you are not comfortable answering unless it is required for service coordination.
Name*

First NameLast Name
Perfered Name (if different)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Brith*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Best Time to Contact you*

MorningAfternoonEarly Evening
Preferred Method of Contact*

EmailPhone CallText Message
Section 2 - Educational Information

This next section of information is educational and will help us support you as you look to continue that education. If you don't know the answer to a question don't worry, we can discuss that further during an in person meeting.
Current School (High School or College )
Current Grade Level or Year in School
Anticipated Graduation Date (Month/Year)
If applicable, list your top five colleges or universities you are considering (Highest Priority First)
Preferred Areas of Study/ Major
Section 3 -Academic Accommodations and Learning Supports

The purpose of this section is to gather information about any academic accommodations or learning supports you have been approved for through your school. This information helps ensure that our services are aligned with your individual learning needs. If you currently have accommodations, please list or select all that apply from the examples below.
Do you currently have approved accommodations at school? (Mark One)

YesNoIn the process of requestingI'm Unsure
If yes, please list any accommodations you use or have used. Examples are provided below; please check all that apply.

Note-taking assistancePreferential SeatingExtended time for examsSeparate or Reduced-distraction testing spaceUse of assistive technologyFlexible attendance or deadlinesOther (Please Describe Below)
Describe any accommodations needed and how they will help if not listed above
Section 4 - Personal Care, Routine, and Independent Living Skills

This section helps us understand your personal care routines and independent living skills, including how well you are able to describe your care needs to others. This information allows us to identify areas where additional support or skill-building may be helpful as you transition into or continue in your educational setting.
Do you understand your personal care routine well enough to explain it to someone else if needed?

YesSomewhatNo
If you answered "yes" or "somewhat" please briefly describe your care routine or key elements of it.
Have you ever worked with an independent living agency or similar organization to receive self-care or personal assistance services?

YesNoI'm unsure
If yes, please describe the type of services received.
Section 5 - Care, Management, Staffing, and Equipment

This section focuses on care management and support systems, including staffing coordination, scheduling, and equipment or assistive device management. Your responses help us understand what level of support you may want or need in managing these aspects of your care.
Are you familiar with managing aspects of your care services, such as scheduling staff or keeping track of staff hours?

YesNoSomewhat
Would you like Support with any of the following? Check all that apply.

Advertising for new staff membersConducting interviews for staffHiring personal care staffTraining or on boarding staffManaging Schedules or Time TrackingUnderstanding and Coordinating Care Service
Are you familiar with the equipment, tools, or assistive devices related to your care routine?

YesSomewhatNo
If applicable, please list or describe any equipment you use.
Section 6 - Additional information
Please share a brief introduction about yourself. You may include anything about your disability or diagnosis that you feel is helpful for us to know, as well as who you are as a person, your interest, and activities you enjoy. (A short paragraph is welcome.)
Consent and Acknowledgment

By signing below, I acknowledge that the information I have provided is accurate to the best of my knowledge. If under the age of 18 a parent or guardian is also required to sign this consent. I voluntarily consent to share this information with Hilary and other consultants working with Hilary's Wheels of Hope for the purpose of receiving appropriate services and support. I understand that ongoing communication is an important part of these services, and I agree to remain in contact with Hilary throughout the time I am receiving services.
Participant Signature

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Participant Print Name
Date
Guardian Signature(if applicable)

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Guardian Print name
Date
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