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Child & Family Advocacy Request Form

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Please initial acknowledgment of the following:

We assist people with intellectual/developmental disabilities (IDD) which is an IQ or adaptive scores of 70 or below. *

An advocate will reach out to you to schedule a free consultation to discuss questions and concerns. *

You may need to provide necessary documents prior to the consultation appointment. (Ex: IEP/504, BIP, evaluations, etc.) *

Please note that a referral does not automatically result in direct advocacy services. *

Preferred language of the family/individual: *

Person Making the Request: *--- Select Choice ---Family/GuardianProfessional

Your Name *

First

Last

Relationship with Youth *

Name of Youth *

First

Last

Your email address *

Your phone number *

Age of Youth *

Gender of Youth *--- Select Choice ---FemaleMaleOther

Youth's Birthday (MM/DD/YYYY) *

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Other *

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

Other *

Address Line 1 *

City *

Zipcode *

Address Line 2

State *

Youth's County of Residence *

School District *

School of Attendance *

Grade *

Issue/Need: *

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

Other: *

What kind of assistance are you needing? Check all that apply. *

• Information and Resources
• Technical Assistance
• Direct Involvement

Is there a meeting scheduled regarding the issue/concern? *

• Yes
• No

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 *

How would you like to meet with the Advocate? *

• In-person at the Arc office
• Virtual Meeting
• Phone call

Additional Information

Please initial acknowledgement of the following:

If possible, we prefer the family to contact us. *

Professionals must have permission from the guardian and provide a Release of Information to submit this request. *

We will not initiate contact with any guardian without their permission. *

Your name *

First

Last

Relationship with Youth *

Your phone number *

Your email address *

Name of Youth *

First

Last

Age of Youth *

Youth's Birthday *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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

Address of Youth *

Youth's County of Residence *

School District *

School of Attendance *

Grade *

Parent / Guardian Name *

First

Last

Phone *

Email *

Family’s Preferred Method of Contact *

• Phone
• Email

Issue/Need: *

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

Other: *

What kind of assistance are you needing? Check all that apply. *

• Information and Resources
• Technical Assistance
• Direct Involvement

Is there a meeting scheduled regarding the issue/concern? *

• No
• Yes

Date, Time, Location of Meeting *

Additional Information

(Release of Information)

serves of schedule

As the Parent/Guardian of *

I am permitting the information contained in the Child and Family Advocacy Request form to be shared with The Arc of Adams County. I understand that signing does not guarantee advocacy services. By signing this Release, I am giving The Arc of Adams County permission to contact me directly.

As a professional, you acknowledge that you have permission from the parent to make this referral? *

• YES

Signature of Professional - (Typing your name here serves as a signature for the release of information.) *

Date *

Submit

Solicitud de Defensoría

Please enable JavaScript in your browser to complete this form. Por favor, ponga sus iniciales para indicar que reconoce lo siguiente: Brindamos asistencia a personas con discapacidades intelectuales y del desarrollo (IDD), lo cual se define como un coeficiente intelectual (CI) o puntajes de habilidades adaptativas de 70 o menos. * Un defensor se comunicará con usted para programar una consulta gratuita y conversar sobre sus preguntas e inquietudes. * Es posible que necesite proporcionar los documentos necesarios antes de la cita de consulta (por ejemplo: IEP/504, BIP, evaluaciones, etc.). * Tenga en cuenta que los servicios de defensa pueden ser una opción si la persona cumple con los requisitos de admisión y elegibilidad. * Persona que realiza la solicitud: *--- Select Choice ---Familia/Tutor(a)Profesional Su nombre * First Last Relación con el/la menor * Su correo electrónico * Su número de teléfono * Nombre del/de la menor * First Last Edad del/de la menor * Fecha de nacimiento del/de la menor (MM/DD/AAAA) * ¿Qué tipo de discapacidad tiene el/la menor? Marque todas las que correspondan. * Discapacidad intelectual Autismo Discapacidad física Discapacidad emocional/conductual Trastorno específico del aprendizaje Otro Desconocido Otro: * Dirección del/de la menor * Address Line 1 Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState Zip Code Condado de residencia del/de la menor * Distrito escolar * Escuela a la que asiste * Grado Escolar * o con Tenga Problema/Necesidad: * Escuela Información sobre discapacidad/beneficios Falta de servicios Salud/Seguridad Comportamiento/Disciplina Necesidades básicas Otro: Otro: * ¿Qué tipo de asistencia necesita? Marque todas las que correspondan. * Información y recursos Asistencia técnica Participación directa ¿Se ha programado una reunión respecto al problema/inquietud? * Sí No Fecha, hora y lugar de la reunión * ¿Cómo desea ser contactado(a) para programar la consulta? *--- Select Choice ---TeléfonoCorreo electrónico ¿Cuándo está disponible durante la semana laboral para la consulta? (De lunes a viernes, de 8:00 a.m. a 5:00 p.m.) Día de la semana * Hora del día * ¿Cómo le gustaría reunirse con el defensor? *--- Select Choice ---Presencial en la oficina de The ArcReunión virtualLlamada telefónica Información adicional Fecha * Submit

Adult Advocacy Referral Form

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Issue/Concern email the

Please initial acknowledgment of the following:

We assist people with intellectual/developmental disabilities (IDD) which is an IQ or adaptive scores of 70 or below who live in Adams County *

We will reach out to you to schedule a free consultation. *

You may need to provide necessary documents prior to the consultation appointment. *

Working with an advocate is time limited and specific depending on the advocacy goal. *

Please note that a referral does not automatically result in direct advocacy services. *

Name of Individual with IDD *

Gender *--- Select Choice ---FemaleMaleOther

Date of Birth *

Age *

Other: *

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

Address *

City *

State *

Zipcode *

County of Residence *

Phone Number of Individual

Email of Individual *

Preferred Language of Individual *

Issue/Concern *

Is there already a meeting scheduled concerning this issue? *--- Select Choice ---YesNo

If yes - date, time, and location?

If yes, with whom?

Is there a legal guardian? *

• Yes
• No
• Unknown

If yes, provide name, relationship, and contact information. *

Your Name (If not Adult with IDD) *

Your Phone (If not Adult with IDD)

Your address (If not Adult with IDD) *

Your email (If not Adult with IDD) *

Relationship to Individual (If not the individual) *--- Select Choice ---Legal GuardianFamilyFriendProfessional

Role *

Organization *

If not the Legal Guardian, do you have a signed Release of Information from the Adult to contact us? *--- Select Choice ---YesNo

Current Services *

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

Name of Agency *

Residential Manager *

Name of Day Program *

Day Program Manager *

School District *

Other Supports in the Individual's life:

Name *

Relationship *

Contact Information *

If this a health and safety issue, does it require reporting to the County Adult Protective Services (APS)? *--- Select Choice ---YesNo

What you need to know about reporting to APS:

If you are a mandatory reporter and you witness or become aware that an at-risk adult with IDD has been or is in imminent risk for mistreatment (abuse, caregiver neglect, or exploitation), you must make a report to law enforcement within 24 hours. 

What steps have been taken to resolve the situation?

Other information to share that is related to the need/issue:

Who is the preferred contact? (Name/relationship) *

Preferred method of contact: *

Best time to contact:

Submit

Trainings offered by the Arc of Adams County staff, these trainings are scheduled by request only.

Self Advocacy Training
This a 4 week class ideal for self advocates to learn and refine their self-advocacy skills. Are you
new to using your self-advocacy skills? Want to increase your skills and confidence to speak up
for yourself? Want to get closer to reaching your goals? This class is for you! Ideal for
independent living programs, day programs, residential programs, advocacy groups. Groups of
10 or less recommended.

View PowerPoint here

For more information contact Joshua Wann, jwann@arcadams.org

Community/Victim Advocacy/First Responder Training
This is a 2 hour in-person/virtual training ideal for professionals wanting to learn more about working with
people with intellectual and developmental disabilities in the community. This training
promotes disability awareness, tips to improve interactions, increase positive outcomes, learn
about community resources, and get any questions asked and answered!

View First Responder PowerPoint here

View Autism Spectrum Disorder PowerPoint here

For more information contact Kari Easterly, keasterly@arcadams.org

Conflict Resolution
This is a 1.5 hour in person/virtual training is ideal for professional in the I/DD system who are struggling with
conflict management. Learn more about your own conflict management style, how to work
better in teams, and how to be more person centered in your approach. Ideal for groups of 10
or less.

View Conflict Resolution PowerPoint here

For more information, contact Kari Easterly at keasterly@arcadams.org

If I Were You and You were Me
This is a 2 hour in-person/virtual training specifically for direct care staff and focused on person centered approaches.
Learn more about how our attitudes and beliefs effect our own behavior, how our behavior
may be contributing to other’s behaviors, learn to be more person centered, and encourage
more positive experiences. Ideal for groups of 10 or less.
For More information, contact Keasterly@arcadams.org

Service and Supports for People with Intellectual and Developmental Disabilities
This is a training about Services and supports in the Developmental Disability System. This is an
hour training that is intended to be interactive so you can get all questions asked and
answered. Ideal for anyone but especially for transition aged individuals and parents.

View PowerPoint here

For More information, contact Keasterly@arcadams.org

Other Helpful Trainings on YouTube/Podcasts from Other Professionals
How to Become your Own PASA 
Self Determination 
Supported Decision Making 

This a 4 week class ideal for self advocates to learn and refine their self-advocacy skills. Are you
new to using your self-advocacy skills? Want to increase your skills and confidence to speak up
for yourself? Want to get closer to reaching your goals? This class is for you! Ideal for
independent living programs, day programs, residential programs, advocacy groups. Groups of
10 or less recommended.

Contact Joshua Wann if interested (720) 634-6888 or jwann@arcadams.org

Kari graduated from Gustavus Adolphus College with a Bachelor’s degree in Psychology, Anthropology and Sociology.  Post college, she immediately started working in the field of intellectual and developmental disabilities and has worked in MN, IL, and South Dakota prior to coming to Colorado in 1997.  She started working at the Arc of Adams County in 2000 as an Adult Advocate and moved into the role of Assistant Executive Director in 2021.  As an Adult Advocate, she provided individual advocacy, worked closely with stakeholder groups regarding systemic advocacy, developed training to community members regarding disability awareness, and screened all adult advocacy requests.  As the Assistant Executive Director, she provides oversight of the individual advocacy program, provides leadership to staff in their advocacy efforts, provides leadership regarding systemic advocacy provided by the advocacy team, and focuses on the agency’s community education and training goals.  When asked what she loves most about working at the Arc of Adams County, she says it is without a doubt the Board’s and staff’s commitment to providing quality individual advocacy supports.

Paula started her advocacy efforts with The Arc of Adams County in 1998.  She has a bachelor’s degree in Special Education and Psychology and a master’s degree in City Planning both from the University of Texas.  Her professional life has been a combination of social work, education and health care. Paula is grateful for the vast learning opportunities she has experienced working with families and other professionals.  She values basic human and civil rights for all; no matter the gifts or challenges we each possess.

Jeannine has been a Child and Family advocate with The Arc of Adams County since 1995. Her background is in Human Services and she has a bachelor’s degree from the University of Buffalo. Her passion comes from knowing that all people are of equal value and entitled to the same rights and opportunities. She often shares how grateful she is to have a career that is so aligned with her personal beliefs.

Since 1985 Linda has been the Executive Director at the Arc of Adams County.  In the early 1960s she learned alongside peers with disabilities in elementary school.  Linda’s Arc journey started as a young teenager in a Youth Arc.  Volunteering at Summer Camp for children with IDD, being a Citizen Advocate for a man living in an institution and helping to remodel the first group home in her community.  Those years created a lasting impact on her commitment to children and adults with intellectual and developmental disabilities. She has a BA in Social Work and her professional career prior to Arc Advocacy was case management and family support in public schools, institutions and community-based services.

Most of her work is systemic, policy and legislative advocacy.  Connections with adults and families who are impacted by services or a lack of services is critical to driving policy.  Any opportunity to assure that children and adults can live, learn, work, play and be accepted in their communities is worth the energy to get there.

For all people, regardless of their abilities or challenges, having a choice is essential to our wellbeing.  Knowing there is someone who supports you to make decisions is important.  The Arc offers the flexibility and strength to make a difference in people’s lives.  Access to independent advocacy is a rare opportunity for many children and adults with IDD.

Kristian began working at The Arc of Adams County in 2017. She is a graduate from Georgia Southern University with a Bachelor of Science in Communications. The Arc has shed light on the injustices and inequalities individuals with Intellectual and Developmental Disabilities face daily. Although, she does not provide direct advocacy, she feels there is a vital role each member of society must play to ensure everyone can live an equal and opportune life. There is always room in our hearts for kindness when you realize everyone is deserving of happiness.