Request edit access
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. 
Sign in to Google to save your progress. Learn more
Email address: *
Name of Child: *
Child's Date of Birth *
MM
/
DD
/
YYYY
Street Address:
City, State and Zip *
Phone: *
Your name: *
Are you a parent, guardian, grandparent, teacher, etc.? *
Please list other resources/supports currently being used? *
Required
I understand that our ASTra Advocates are Lay Advocates, and nothing we discuss should be construed as legal advice.  *
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.  *
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): *
How did you hear about us?
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. 
What is his/her first language? (English, ASL, Spanish, etc.) *
Does your child have a current Communication Plan on their IEP?
Clear selection
Describe your child's communication at school. Provide a description of communication/language used, and any difficulties you see in school:
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:
Hearing level of child, i.e., mild, moderate, severe, profound:  
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. 
Please indicate the child’s primary eligibility on their IEP (For example; Deafness/hearing loss, Autism, developmental delay, learning disability, ADHD, etc.)
Do you have concerns about your child’s ability to learn?
Please indicate your child’s functioning compared to grade level in Reading, Writing, and Math:
School Name, Phone number, and District:
What grade is your child in?
What is your child's placement?
List name, email address, and role of professional service providers most familiar with and understanding of your child and the situation:
Does CO Hands & Voices have permission to contact the above listed professionals?
Clear selection
Others on the IEP team:
Advocacy topics that need to be covered:
Please explain the Advocacy Issues listed above.
Please list relevant information regarding the identification of your child’s hearing loss, as well as early intervention and educational history:
If you made a written request to the school related to your child’s IEP, please describe the request briefly here:
Has the Local Education Agency (LEA) - school, or IEP team responded to your request or proposal? 
Clear selection
 Please include other resources/supports not listed above:
Current status and next scheduled meeting(s) pertaining to this issue:
What do you hope to accomplish?
Please describe how you would like CO Hands & Voices to help you:
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/
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report