Name *

First Name

Last Name

I have reviewed the privacy policy, terms of use, and disclaimer found at www.apathfrowardadvocate.com *

Yes

Today's Date *

MM

DD

YYYY

Which School District does your child attend? *

Hall County

Gwinnett County

Buford City Schools

We are out of district

We do not attend a GA school

Does your child currently have (check all that apply) *

Academic problems

Emotional, Behavioral, or Attention Problems

Medical Problems

Have your previously tried to get your child services? *

Yes

No

Has your child been evaluatied and/or diagnoesd by any private providers? *

(Ex. psychologist, speech therapist, doctor, etc?)

Yes

No

Do you currently have an IEP or school meeting scheduled? *

Yes

No

If yes, what is the date of your meeting?

MM

DD

YYYY

Are you ready to put down a deposit of $350 to begin advocacy services within the next week? *

Yes

No

Preferred Meeting Date *

Note: All calls at 11 a.m. EST

MM

DD

YYYY