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SpEd Advocate Contact Form

Email *

Answering optional questions will expedite help for your child

Your first name *

Your last name *

Child's given (first) names (Include nickname in parentheses) *

If you are contacting us about more than one child, please fill ouit a second form. You need not answer demographic questions unless they are different (e.g. different the parent)

Child's last name (if different from your last name)

Your Relationship with Student/Child *

Mother

Father

Legal Guardian

Job Applicant

Service Provider

Grandparent (not legal guardian)

Friend

I am an adult over 21 with a disability

Student

Other:

School District of Child's Residence *

This is the name of the District, usually where you live. If not known, enter the borough, town or city where the student lives. Enter the current school or placement in the next section.

Mobile phone# (10 digits) *

Home phone# (10 digits, if you have one)

Work phone#

Minimum 10 digits, add ";" and extension if applicable

What is your child's diagnoses, difficulty or disability *

Select as many as applicable from MD or other expert diagnoses; listed suspected diagnoses under Other

ADHD (Combined, Inattentive or Impulsive)

Audio Processing Disorder or Decoding APD (DAPD)

Autism Spectrum Disorder (including Asperger's Syndrome)

Anxiety (GAD, Social, Body Dysmorphic Disorder (BDD)

Blind or vision Impaired

Deaf or Hard of Hearing (including Cochlear Implant)

Depression

Down Syndrome

Dyscalculia (unable to do age appropriate math)

Dysgraphia (unable to do age appropriate written work - not handwriting/Small Motor

Dyslexia (e.g. unable to decode words into sounds)

Executive Function Deficit (e.g. organization)

Genetic Disorder (Check and Specify type in Other)

Gross Motor Deficit e.g. requires Physical Therapy (PT)

Handwriting or other Small Motor Deficit

Intellectual Disability (ID)

Oppositional Defiant Disorder (ODD)

Obsessive Compulsive Disorder (OCD)

Pervasive Development Delay (PDD)

Reading Comprehension or other Specific Learning Disorder

School Refusal (more than 10 days/school year)

Speech and Language (Articulation, Expressive, Receptive or Pragmatic Language including non-speaking.)

Other:

Required

Provide a one sentence statement about the MOST important problem you are trying to solve (not history) *

The problem can be I need to know what plan, services, accommodations, goals and objectives are most appropriate for my child, e.g. in their 504, IEP

What is the current date? *

YYYY

We are professional (paid) advocates. Is this what you are looking for? *

To be fair to other parents, kindly be honest

Yes

No, I am looking for free advice. Please refer me.

Not sure, I want to know what an Advocate can do for me.

No, I am a service provider, job seeker, or other

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