Intake Form

Dyslexia Advocacy Action Group

Confidential Questionnaire for Educational Advocacy/Free Consultation

Are you filling this out because you are part of the class action lawsuit?

* Indicates required field

Select One *

Your Information:

How can we help you? *

Free One Hour Consultation I need an advocate

Name (Primary Parent or Guardian) *

First

Last

Phone Number *

Email *

Confirm Email *

Name (Secondary Parent or Guardian) *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Confirm Email *

How did you hear about Dyslexia Advocacy Action Group? *

Child's Information:

Age *

Grade *

Name of School District *

Eligibility:

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

What services has your child received? *

What evaluations has your child recently received? *

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:

helen@dyslexiaadvocacyactiongroup.org

Submit

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

Dyslexia Advocacy Action Group

Confidential Questionnaire for Educational Advocacy/Free Consultation

Are you filling this out because you are part of the class action lawsuit?

Your Information:

Child's Information:

Eligibility:

Funding for Underprivileged Children

Goals of Educational Advocacy:

Give the Gift of Reading this Year

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

Dyslexia Advocacy Action Group

Confidential Questionnaire for Educational Advocacy/Free Consultation

Are you filling this out because you are part of the class action lawsuit?

Your Information:

Child's Information:

Eligibility:

Funding for Underprivileged Children

Goals of Educational Advocacy:

​Give the Gift of Reading this Year

Give the Gift of Reading this Year