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CONTACT INFORMATION
     Name:   
     Relation to Student:  
     Telephone:  
     Email:  
     Contact Preference:   PhoneEmail                    Zip Code   

     How did you hear about us?  

     We are located in PENNSYLVANIA. We serve Indiana County and Armstrong County.

STUDENT INFORMATION
     Student Name:   
     Student's School:  
     Student's Age:             Student's Date of Birth:  
     Student Currently Has:   IEP504 PlanEvaluation in ProgressNone

PRESENT CONCERNS LEADING TO ADVOCATE INTAKE
Please briefly describe the issue(s) you and the student are experiencing:

Please describe in detail the steps you have taken to inform the school/school district (i.e., IEP/504 team, teacher, principal, special education director) about your concerns and to explore possible solutions:
     

Please describe in detail the specific educational concerns and goals you would like to address to enhance student success:
     

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CONTACT INFORMATION
     Name:   
     Email:   
     Telephone:  
     Contact Preference:   PhoneEmail

CONCERNS
Please describe in detail the questions / needs / concerns and other information to include so that we can best assist you