Adult Advocacy Consulting Intake Form

Advocacy Consultation Intake Form -

This intake form helps in understanding what situation is being faced, helping identify your goals, and determining the best way to provide support. *Advocacy consulting services are non-legal in nature. We do not provide legal advice or representation.*
Note

Advocacy services focus on the needs and goals of the person with a disability. Family consultation is provided when it supports those outcomes. The acronym PWD is used meaning Person with Disability
Are completing this intake for yourself or on behalf of some else?*
What is the name of Person with Disability (PWD) needing advocacy

First NameLast Name
What is your name?

First NameLast Name
What name do they like to go by?
What name do you like to go by?
Date of Birth (PWD)*

MonthDayYear
Family memberFriendConservator (non family)Service Provider (case manager, staff, medical professional, agency)Other
Contact Information

Please complete using the information of the person who is best quipped to provide needed information.
Name of person completing this intake?*

First NameLast Name
Address *

Street Address Line 2
CityStateZip Code
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email of person completing form*
example@example.com
PhoneEmailText
Advocacy/ Consultation Needs

To help us identify barriers, determine eligibility pathways, and look at possible advocacy strategies. Please fill out the following. ONLY SHARE WHAT YOU ARE COMFORTABLE WITH SHARING.
I consent
Is there anything about your disability, support needs, or service history that would help us better understand how to support you?
This information will not be shared
TennCareSSI/SSDIVocational RehabilitationTN StartECF ChoicesMAPSCHOICESICF/IIDNone yet1915c - SD, SW, CACFamily SupportKatie BeckettOther
Are there any accommodations you may need to participate in advocacy meetings? (if so what do they look like)
Advocacy/ Consultation Needs

To help us identify barriers, determine eligibility pathways, and look at possible advocacy strategies. Please fill out the following. ONLY SHARE WHAT YOU ARE COMFORTABLE WITH SHARING.
Service NavigationService PlanningProvider ConflictTransition Support as child moves into adulthoodAdvocacy StrategyResource MappingCrisis NavigationMeeting PreparationTrainingOther
What are the top three priorities you would like advocacy help with right now?
Examples: keeping services, understanding options, resolving a denial, preparing for a meeting, finding resources.
Anything else we should know?
Note on Fees

Our Advocacy and Consultation services use a flat fee structure to keep costs clear, predictable, and fair. Fees help support the time spent reviewing information, preparing guidance, and helping individuals and families navigate complex systems. Reduced or sliding-scale fees may be available when possible. No one is denied basic consultation due to inability to pay.
I could pay a reduced feeI would need sliding scaleI cannot pay currentlyPrefer to discuss
Urgency Level

1

2

3

4

5

1 is Not Urgent, 5 is Very Urgent
Should be Empty:

Advocacy Consultation Intake Form -

Note

Contact Information

Advocacy/ Consultation Needs

Advocacy/ Consultation Needs

Note on Fees