3 in 1 Advocacy

3101 W. 6th Street #470154
Fort Worth, TX 76147

682-382-0218

Thank you so much for contacting 3 in 1 Advocacy! Please read the privacy policy below, and then fill out this form in its entirety prior to scheduling/booking a consultation. This information helps us make the most of that shortened period of time available for your free consultation.

Privacy Policy

All information received from a client is strictly confidential. 3 in 1 Advocacy takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

All personal information will only be used in the event that you hire 3 in1 Advocacy to provide services to you and/or your child, and then only when necessary in limited use during the course of your case.

If you have any questions, please don't hesitate to contact us directly. We look forward to the opportunity to serve your needs!

Contact information: Contact 1

Prefix

First name *

Middle name

Last name *

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Preferred Contact Method

Please acknowledge that you have read and hereby accept the above privacy policy regarding use of my personal information by typing your full legal name below

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

Contact information: Child's Name

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Do you have legal decision-making authority for educational matters involving this child?

Yes

Name of Child's School:

In what school district?

In what grade is this child enrolled in the current school year?

In which special programs does this child participate? (Choose all that apply)

Special Education (with an IEP)Section 504 (with a 504 Plan)Emergent Bilingual (with linguistic accommodations)Gifted and Talented (with advanced academics activities)Multi-Tiered Systems of Support (formerly known as RtI or Response to Intervention)

Are there accommodations already in place for your child?

Yes

Does this child have a behavior intervention plan (BIP) already in place?

Yes

Does this child have an individual health plan (IHP) already in place?

Yes

What are your current concerns?

How long have you had these concerns?

Have you made the school aware of these concerns?

Yes

Has the school tried to address these concerns?

Yes

How can 3 in 1 Advocacy help you?

What would you like to see happen?

Were you referred to us by someone or an organization?

Yes

Contact information: Contact 1

Preferred Contact Method

Please acknowledge that you have read and hereby accept the above privacy policy regarding use of my personal information by typing your full legal name below

THANK YOU

Contact information: Child's Name

Do you have legal decision-making authority for educational matters involving this child?

Name of Child's School:

In what school district?

In what grade is this child enrolled in the current school year?

In which special programs does this child participate? (Choose all that apply)

Are there accommodations already in place for your child?

Does this child have a behavior intervention plan (BIP) already in place?

Does this child have an individual health plan (IHP) already in place?

Related Services your child currently receives. (Check all that apply.)

What are your current concerns?

How long have you had these concerns?

Have you made the school aware of these concerns?

Has the school tried to address these concerns?

How can 3 in 1 Advocacy help you?

What would you like to see happen?

Were you referred to us by someone or an organization?