Intake Form

Fill out the confidential advocacy form, and we will contact you within 24 hours

Form for Parent Advocate & Free Consultation

Confidential Questionnaire for Educational Advocacy

Your Information:

* Indicates required field

Email *

Confirm Email *

Name (Primary Parent or Guardian) *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name (Secondary Parent or Guardian) *

First

Last

Phone Number *

Email *

Confirm Email *

How did you hear about Dyslexia Advocacy Action Group? *

Child's Information:

Age *

Grade *

Name of School District *

What services has your child received? *

What evaluations has your child recently received? *

Eligibility:

Does your child have a 504, IEP or BIP? *

Has your child been diagnosed or classified? *

Select One ↓ YES NO

What is your child's diagnosis or classification? *

Upload: IEP/504, Latest Evaluation & Latest School Report *

Max file size: 20MB

Funding for Underprivileged Children

We are applying for grants so that we can offer free advocacy to families that qualify. Please check YES if your child receives free school meals, you may be eligible if we currently have funding. Otherwise, we offer sliding-scale advocacy.

Does your child receive free or reduced cost school meals? *

YES NO REDUCED COST SCHOOL MEALS

Goals of Educational Advocacy:

Explain your concerns, and your advocacy goals: *

If you are having problems uploading large files or with the form, email us:

[email protected]

Submit

Fill out the confidential advocacy form, and we will contact you within 24 hours