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Advocacy Request Form
Thank you for connecting with the Colorado Hands & Voices ASTra Educational Advocacy Program. Please fill out this form completely to help us understand your situation and provide us the necessary information to support you in your child’s education planning. If you have a copy of your child's IEP/504/IFSP, or any letters of documentation, please email them to us at ASTra@co-hv.org so we can better help you.
We cannot schedule a time with you to talk or plan to attend any meetings with you until this form is completed, and the Release of Liability for is signed
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Email address:
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Your answer
Name of Child:
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Your answer
Child's Date of Birth
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MM
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DD
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YYYY
Street Address:
Your answer
City, State and Zip
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Your answer
Phone:
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Your answer
Your name:
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Your answer
Are you a parent, guardian, grandparent, teacher, etc.?
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Your answer
Please list other resources/supports currently being used?
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Parent Training Center
Advocacy Organization
Legal Advice
Other
N/A
Required
I understand that our ASTra Advocates are Lay Advocates, and nothing we discuss should be construed as legal advice.
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Yes
No
I understand that COH&V Lay Advocates work very part time, and it sometimes may take 72 hours for them to get back to you.
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Yes
No
I am reaching out to Colorado Hands & Voices to request a ASTra Advocate to help me with (we understand this may change during our discussions):
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Coaching/Teaching me about my child's IFSP
Coaching/Teaching me about my child's IEP/504
Attending my child's IFSP Meeting to help me advocate for my child.
Attending my child's IEP/504 Meeting to help me advocate for my child.
How did you hear about us?
Your answer
Communication Choice/Methodology - How does your child prefer to communicate? Please note their preference for expressive language may differ from their preference for receptive language, and that's absolutely fine. For example: Expressively my child prefers to talk, and receptively s/he prefers a combination of spoken language and sign support.
Your answer
What is his/her first language? (English, ASL, Spanish, etc.)
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Your answer
Does your child have a current Communication Plan on their IEP?
Yes
No
What's a Communication Plan?
Clear selection
Describe your child's communication at school. Provide a description of communication/language used, and any difficulties you see in school:
Your answer
Tell us about the communication/language used, and any difficulties you see in settings such as at home, with friends, with siblings, and/or out in the community:
Your answer
Hearing level of child, i.e., mild, moderate, severe, profound:
Your answer
Does the child use amplification? If so, what time, and how much do they use their device(s) to access sound and language? Examples: My child uses two hearing aids and wears them all waking hours, or my child uses a CI and a hearing aid. She wears them at school, then takes a break at home.
Your answer
Please indicate the child’s primary eligibility on their IEP (For example; Deafness/hearing loss, Autism, developmental delay, learning disability, ADHD, etc.)
Your answer
Do you have concerns about your child’s ability to learn?
Your answer
Please indicate your child’s functioning compared to grade level in Reading, Writing, and Math:
Your answer
School Name, Phone number, and District:
Your answer
What grade is your child in?
Your answer
What is your child's placement?
Self-contained
State School for the Deaf
Mainstreamed
Center-based
Neighborhood School
Combination
Other
List name, email address, and role of professional service providers most familiar with and understanding of your child and the situation:
Your answer
Does CO Hands & Voices have permission to contact the above listed professionals?
Yes
No
Clear selection
Others on the IEP team:
Your answer
Advocacy topics that need to be covered:
Academic Standards
Accommodations
Assessments
Assistive Technology: (RM/FM, Smart board, etc.)
Audiological Concerns
Behavior
Cochlear Implant Re/Habilitation
Communication Access/Communication Plan
Communication Choices/Modes
Educational Placement
Eligibility
IEP Compliance
IEP Goals & Objectives
Interpreters
LRE (Least Restrictive Environment)
Mainstream Supports
Other labels
Peers & Deaf/HH Role Models
Proficiency of Staff
Services
Transition between programs
Other
Please explain the Advocacy Issues listed above.
Your answer
Please list relevant information regarding the identification of your child’s hearing loss, as well as early intervention and educational history:
Your answer
If you made a written request to the school related to your child’s IEP, please describe the request briefly here:
Your answer
Has the Local Education Agency (LEA) - school, or IEP team responded to your request or proposal?
Yes
No
N/A
Clear selection
Please include other resources/supports not listed above:
Your answer
Current status and next scheduled meeting(s) pertaining to this issue:
Your answer
What do you hope to accomplish?
Your answer
Please describe how you would like CO Hands & Voices to help you:
Your answer
Our advocacy services depend largely on voluntary support. Your membership donation to the CO Hands & Voices Chapter helps provide this type of support to families, and priority is given to members. Are you a current member of the CO Hands & Voices Chapter? If you'd like to join, go to:
https://www.co-hv.org/newsite/about/become-hv/
Yes
No
I don't know
Clear selection
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