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info@arcadams.org

641 E. 112th Ave. Northglenn, CO
80233

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641 E 112th Ave, Northglenn, CO 80233

Email: info@arcadams.org
Phone: (303) 428-0310

The Arc of Adams County is an independent advocacy organization serving individuals with Intellectual and Developmental Disabilities (IDD) within Adams County.

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Child/Youth Advocacy Request Form

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Preferred language of the family/individual *

Add Language *

Name of Youth with IDD *

Gender of Youth *

Other *

Address Line 1 *

Address Line 2

City *

State *

Zipcode *

County *

Youth's Date of Birth (MM/DD/YYYY) *

What type of disability does the Youth have? (Check all that apply.) *

Intellectual Disability
Autism Spectrum Disorder
Physical Disability
Emotional/Behavioral Disability
Specific Learning Disability
Other
Unknown

School District

School of Attendance

Grade

Issue/Need.(Check all that apply): *

Education
Disability/Benefit information
Lack of Services
Health/Safety
Behavior/Discipline
Basic Needs
Other

Other issue:

Is there a meeting scheduled regarding the issue/concern?

Yes
No
N/A

Layout Attendance the

Date, Time, Location of Meeting *

How do you want to be contacted to schedule the consultation? *

Phone
Email

When are you best available during the work week for the consultation? (Monday through Friday, 8:00 am to 5:00 pm)?

Day of the Week

Time of Day

Person Making the Request: *

Name *

Relationship to Youth *

Phone Number *

Email *

Name *

Role/Title *

Agency/School *

Email *

Phone Number *

Who is the preferred contact?

Contact Name *

Contact Relationship *

Contact Phone Number *

Contact Email *

Is the person aware that this referral is being submitted? *

Yes
No

Adult Advocacy Interest Form

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The Arc of Adams County assists individuals with documented Intellectual/Developmental Disabilities (IDD).

While we can’t guarantee that we’ll be able to provide assistance to everyone that completes this form, we’re committed to doing our best to help individuals and families in Adams County who are in need of support.

Due to the high number of requests, it may take up to 5 business days for a response. Please note: Advocates schedules may book out several weeks in advance.

Preferred language of the family/individual: *

Other Language *

Information about the adult with IDD:

Name of Adult with IDD *

Email *

Phone Number *

Date of Birth *

Gender *

Street Address Line 1 *

Street Address Line 2

City *

Zip Code *

State *

County *

What type of disability does the individual have? (Check all that apply.)

Intellectual Disability
Autism Spectrum Disorder
Physical Disability
Emotional/Behavioral Disability
Specific Learning Disability
Other
Unknown

Current Services *

SLS Waiver
DD Waiver
Residential Program
Day Program
Transition Program with School District
Other
Unknown

Case Management Agency *

Case Manager *

School District *

1 Adult about

Provide more details about your request *

Is there a legal guardian?

Yes
No
Unknown

Guardian Name *

Relationship to individual *

Guardian Phone *

Guardian Email *

Are you making this request for someone else? *

Yes
No

Name *

Role/Title *

Agency *

Phone *

Email *

Is the person aware that this referral is being submitted? *

Yes
No

Who is the preferred contact?

Contact Name *

Contact Relationship *

Contact Phone Number *

Contact Email *

How does the preferred contact want to be contacted to schedule the consultation? *

Phone
Email

When are you available during the work week for the consultation? (Monday through Friday, 8:00 am to 5:00 pm)

Day of the Week

Time of Day

Volunteer Interest Form

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Name *

Number Name Volunteer

Email ID *

Phone Number *

Volunteer Area of Interest *

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Sponsorship Interest Form

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Name Email Phone

Name *

Organization *

Email Address *

Phone *

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Community Inquiry Form

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Name *

Organization Name *

Email ID *

Phone Number *

Name Number ID

Message