24/25 Advocacy Support Intake Form Parent/Guardian Information
Relationship to Child
- Select - Parent Guardian Other
Would you like to add contact information for a second/parent guardian?
Relationship to Child
- Select - Parent Guardian Other
Age
- Select - 5 or under 6 7 8 9 10 11 12 13 14 15 16 17 18 19+
- Select - Not Yet School Age Kindergarden Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 Graduated
Location & School District Information
Province/Territory
- Select - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
What type of school does your child attend?
BC School District
- Select - 05 Southeast Kootenay 06 Rocky Mountain 08 Kootenay Lake 10 Arrow Lakes 19 Revelstoke 20 Kootenay-Columbia 22 Vernon 23 Central Okanagan 27 Cariboo-Chilcotin 28 Quesnel 33 Chilliwack 34 Abbotsford 35 Langley 36 Surrey 37 Delta 38 Richmond 39 Vancouver 40 New Westminster 41 Burnaby 42 Maple Ridge-Pitt Meadows 43 Coquitlam 44 North Vancouver 45 West Vancouver 46 Sunshine Coast 47 Powell River 48 Sea to Sky 49 Central Coast 50 Haida Gwaii 51 Boundary 52 Prince Rupert 53 Okanagan Similkameen 54 Bulkley Valley 57 Prince George 58 Nicola-Similkameen 59 Peace River South 60 Peace River North 61 Greater Victoria 62 Sooke 63 Saanich 64 Gulf Islands 67 Okanagan Skaha 68 Nanaimo-Ladysmith 69 Qualicum 70 Pacific Rim 71 Comox Valley 72 Campbell River 73 Kamloops-Thompson 74 Gold Trail 75 Mission 78 Fraser-Cascade 79 Cowichan Valley 81 Fort Nelson 82 Coast Mountains 83 North Okanagan-Shuswap 84 Vancouver Island West 85 Vancouver Island North 87 Stikine 91 Nechako Lakes 92 Nisga'a 93 Conseil scolaire francophone 200 IGroup No Zeros 5 Southeast Kootenay 6 Rocky Mountain 8 Kootenay Lake 10 Arrow Lakes 19 Revelstoke 20 Kootenay-Columbia 22 Vernon 23 Central Okanagan 27 Cariboo-Chilcotin 28 Quesnel 33 Chilliwack 34 Abbotsford 35 Langley 36 Surrey 37 Delta 38 Richmond 39 Vancouver 40 New Westminster 41 Burnaby 42 Maple Ridge-Pitt Meadows 43 Coquitlam 44 North Vancouver 45 West Vancouver 46 Sunshine Coast 47 Powell River 48 Sea to Sky 49 Central Coast 50 Haida Gwaii 51 Boundary 52 Prince Rupert 53 Okanagan Similkameen 54 Bulkley Valley 57 Prince George 58 Nicola-Similkameen 59 Peace River South 60 Peace River North 61 Greater Victoria 62 Sooke 63 Saanich 64 Gulf Islands 67 Okanagan Skaha 68 Nanaimo-Ladysmith 69 Qualicum 70 Pacific Rim 71 Comox Valley 72 Campbell River 73 Kamloops-Thompson 74 Gold Trail 75 Mission 78 Fraser-Cascade 79 Cowichan Valley 81 Fort Nelson 82 Coast Mountains 83 North Okanagan-Shuswap 84 Vancouver Island West 85 Vancouver Island North 87 Stikine 91 Nechako Lakes 92 Nisga'a 93 Conseil scolaire francophone
Advocacy Support Overview
Select the type of advocacy support you are interested in:
Which description best fits your situation? Check all that apply:
Please describe your situation:
Indicate any professionals currently on your child's support team. Check all that apply.
Are any of these professionals involved in helping you advocate for your child at school?
Please specify which professionals and their role in advocating for your child:
Child’s Formal Medical Diagnoses (Please check all that apply):
Does the child have any of the following plans in place? Check all that apply.
Primary IEP Designation
- Select - A - Physically Dependent B - Deafblind C - Intellectual Disability D - Chronic Health E - Visual Impairment F - Deaf or Hard of Hearing G - Autism H - Mental Health K - Intellectual Disability P - Gifted Q - Learning Disability R - Mental Health I'm not sure
Describe your current educational concerns:
What is your primary goals for advocacy support?
Do you have any upcoming meeting with the school team scheduled?
Select your method of payment for advocacy support services:
Have you submitted an RTP for my services as a Behaviour Consultant and received approval from AFU?
AFU Clients: To ensure we can begin our work promptly, please submit a Request to Pay (RTP) for 5 hours of work at $135/hour (totalling $675) and obtain approval from the Autism Funding Unit. This step is crucial for a smooth start to our collaboration. Please note that processing can take up to 6 weeks, so I recommend submitting your RTP as soon as possible to avoid delays.
Consent & Privacy I am committed to protecting your privacy and ensuring the confidentiality of your information. By submitting this form, you consent to me collecting and using your information to provide advocacy support services. Your information will be kept confidential and not shared without your consent.
SUBMIT INTAKE FORM
