Advocacy Intake Form Please provide the information for the individual requesting support. Inquiry Type:(Required) One-to-one Advocacy Information/Resources Reason for Inquiry:(Required) Early Intervention/Transition IEP Issues (K-12+) Placement Transition Guardianship vs. Power of Attorney (POA) Adult IDD Assistance Other Individual's Contact InformationPlease complete this section for the person interested in receiving advocacy support and/or resources.Individual's Name:(Required) First Last Pronoun(s): Primary Language(s) Spoken(Required) English Spanish Other Other Language(s) Spoken Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone:(Required)Email:(Required) Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence:(Required) Lehigh Northampton Other Additional InformationPlease complete this section for the person interested in receiving advocacy support and/or resources.Disability/Diagnosis:(Required) If over 18, does the individual have a legal guardian or Power of Attorney (POA)?(Required) Yes No POA/Guardian's Name:(Required) First Last Agency: POA/Guardian's Phone:(Required)POA/Guardian's Email:(Required) Do you/the individual have a Supports Coordination Agency? Yes No Agency Name:(Required) School District: School Name: Have you received Advocacy support from us before(Required) Yes No Year: Summary of Concerns/Reason for Inquiry:(Required)Please tell us more about the concerns and/or the individual are experiencing. DemographicsPlease complete the below questions based on the individual for whom you are completing the form. This section is optional and used for grant writing purposes. All data collected is separated from the individual's name. Please indicate individual’s race (OPTIONAL): American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White, Caucasian Do not wish to disclose Please indicate individual’s ethnicity (OPTIONAL): Hispanic or Latino or Spanish Origin Non Hispanic or Latino or Spanish Origin Do not wish to disclose Please indicate individual’s gender (OPTIONAL): Female Male Transgender Non-binary/non-conforming Do not wish to disclose Other Person Completing the FormRelationship to Individual:(Required) Self Parent/Family Member Supports Coordinator Education Personnel (Principal, Guidance Counselor, Teacher, etc.) Agency/Program Staff Agency Name:(Required) Name of Person Completing this Form:(Required) First Last Is your contact information the same as the individual’s listed above?(Required) Yes No Phone:(Required)Email:(Required) Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County:(Required) How did you learn about our services:(Required) Arc Staff Arc Website Bi-County Newsletter Education Personnel (Teacher, Staff, Intermediate Unit, etc.) Family/Friend Parent Support Group Social Media (Facebook, LinkedIn, Email Blasts) Supports Coordination Agency Other Would you be interested receiving the Lehigh & Northampton Bi-County Newsletter?(Required) Yes No Already receive it
