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Advocacy Request

Person needing Advocacy assistance

Person submitting Advocacy form

Relationship of person submitting form to person needing Advocacy

Email of person submitting Advocacy form

Email of contact person for Advocacy Intake

Phone

Does the person know you are contacting The Arc for help for them

YES

NO

What help are you requesting

Education Advocacy

Child non education Advocacy

Adult Advocacy

Disability

Intellectual Disability

Autism

Other

Age of person needing Advocacy help

Briefly describe the Advocacy help needed

County where person who needs Advocacy help lives

Lancaster County

Lebanon County

Other

School District if Educational Advocacy Needed

Name of Supports Coordinator (If known)

Supports Coordination Agency

What Waiver does the person have, if any?

Consolidated

Community Living

PFDS

Autism

Other

Are you working with anyone else on this issue?

Who referred you to The Arc?

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Lititz, PA 17543

(717) 394-5251

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