General Advocacy Intake Form

It is our pleasure to serve you and your loved ones. To request general advocacy, please fill out the form below. Please note that we serve El Paso, Park, and Teller Counties. If you need to find a chapter of The Arc in your local area, please click here. Please allow one business week for a response from one of our advocates. If you have any questions, please give us a call at (719) 471-4800.

The Arc Pikes Peak Region General Advocacy Intake Form

Person's Name (Being referred)

Person's email address

Date of Referral

Date of Birth

Individual Address *

Person's Phone

Home Phone

Work Phone

Cell Phone

Is it OK to contact the person directly?

Yes

If no, please ihclude the name, telephone number, and email address of the approporiate contact:

Please list all agencies involved with providing services and the type of services provided to be they person.

Person Making Referral

Address

Home Phone

Work Phone

Cell Phone

Agency Making Referral:

Reason for Referral:

Does the person have family involvement? (please explain)

Is the person able to make decisions for themselves? (please explain)

What types of decisions does the person require support with? (i.e. medical decisions, financial decisions, etc.)

Please describe the need for advocacy

Are there judicial issues? (please be specific)

What are the expectations for advocacy?

Does the person have knowledge of this referral and agree / consent with this request? If not, please explain why:

Please include any additional information that is pertinent to this request. Please attach an additional sheet / additional documentation if necessary.

Additional Documentation

How did you hear about The Arc Pikes Peak Region?

If you are interested in guardianship, please contact Christina Butero at christina@thearcppr.org

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General Advocacy Intake Form

The Arc Pikes Peak Region General Advocacy Intake Form

Person's Phone

Reason for Referral:

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