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Advocacy Request Form
We appreciate your interest in the Hands & Voices ASTra Education Advocacy Program. While it can be difficult to put into words the many concerns you may have about your child, 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.
We cannot schedule a time with you to talk or plan to attend any meetings with you until this form is completed.
If you have letters and/or supporting documentation, please attach them to your email submission. We know this is a long form, but it will be helpful to your child’s IEP or 504!
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Email Address:
*
Your answer
Name of Child:
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's current age
*
Your answer
Street Address:
Your answer
City, State and Zip
Your answer
Phone:
*
Your answer
Name of Family Contact:
Your answer
Role of Family Contact, and Role (Parent, Guardian, etc.)
Your answer
Name and contact information of the person who referred you to us:
Your answer
May we contact the referring person if needed?
Yes
No
Clear selection
Communication Choice/Methodology - How does your child prefer to communicate? (Check one or any combination & indicate which is the Primary Mode, and whether that is receptive or expressive use.)
American Sign Language (ASL)- Expressive
American Sign Language (ASL)- Receptive
Spoken English- Expressive
Spoken English- Receptive
Total Communication (combination of spoken and sign)- Expressive
Total Communication (combination of spoken and sign)- Receptive
Cued Speech- Expressive
Cued Speech- Receptive
Sign Systems (ex: SEE/CASE, etc.)- Expressive
Sign Systems (ex: SEE/CASE, etc.)- Receptive
Other
What is his/her first language? (English, ASL, Spanish, etc.)
*
Your answer
Does your child have a current Communication Plan on the IEP?
Yes (Please send the most up to date form to
astra@co-hv.org
)
No
What's a Communication Plan?
Clear selection
Describe the communication in your home and at school. Provide a description of communication/language used and any difficulties you see in school:
Your answer
Describe the communication/language used and any difficulties you notice at home:
Your answer
Provide a description of communication/language used and any difficulties you see with siblings:
Your answer
Describe the communication/language used and any difficulties you observe with D/HH friends:
Your answer
Provide a description of communication/language used and any difficulties you see with hearing friends:
Your answer
Tell us about the communication/language used and any difficulties you see in other settings:
Your answer
Hearing level of child, i.e., mild, moderate, severe, profound: (May attach audiogram to email)
Your answer
Does the child use amplification?
Hearing Aid
Bone Conduction Aid
Cochlear Implants
All waking hours
Only during school
Other
Hearing Aid
Bone Conduction Aid
Cochlear Implants
All waking hours
Only during school
Other
Clear selection
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, & 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 Issues:
Academic Standards
Accommodations
Assessments
Assistive Technology: (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 and attach to email:
Your answer
Has the Local Education Agency (LEA) - school, or IEP team responded to your request or proposal? (please email copies if you have it in writing)
Yes
No
N/A
Clear selection
Please list other resources/supports currently being used?
Parent Training Center
Advocacy Organization
Advocate
Other
N/A
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 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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