Individual & Family Support Advocacy Intake Form
Please complete this form to help us understand your family's needs.
Your Full Name (Parent, Guardian, Authorized Representative, or Self)
*
Relationship to the Individual
*
Self
Parent
Legal Guardian
Conservator
Authorized Representative
Family Member
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home Address
*
Street Address
Street Address Line 2 (N/A if it’s the same as the above address).
City
State / Province
Postal / Zip Code
Preferred Method of Contact
*
Phone
Text
Email
Name of the Individual Receiving Advocacy Services
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of Individual Receiving Advocacy Services
School or Educational Program Currently Attending (if applicable)
Grade Level (if applicable)
Has the individual receiving advocacy services been diagnosed with any of the following?
Autism Spectrum Disorder
Developmental Delay
Speech Delay
ADHD
Sensory Processing Differences
Behavioral Challenges
Other
Other diagnosis (please specify)
Is the individual receiving advocacy services connected to a Regional Center?
*
Yes
No
In the process
Regional Center Name
Service Coordinator's Name
Does the individual receiving advocacy services have an Individual Program Plan (IPP)?
*
Yes
No
In Progress
Does the individual receiving advocacy services have an Individualized Education Program (IEP)?
*
Yes
No
Currently being evaluated
School or Educational Services Currently Provided (if applicable)
Speech Therapy
Occupational Therapy
Behavioral Support
Specialized Academic Instruction
Other
Other School or Educational Services (please specify, if applicable)
What type of support are you seeking?
Family Navigation / Advocacy
Help understanding Regional Center services
IEP preparation support
Enrichment programs
Social development programs
Movement / motor development activities
Community participation opportunities
Other
Referred By: (How did you here about us)
Please describe the individual’s strengths and the areas where support is needed.
Allergies or medical conditions
Safety considerations
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of Individual, Parent, Guardian, or Authorized Representative
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: