I have reviewed the Referral Guide above and believe this referral is in ACL's Scope of Direct Advocacy.

Yes, I have reviewed the Referral Guide.

I understand that the ACL cannot engage in discussion about this situation until a signed Release of Information (ROI) is submitted. I understand that the ROI should be submitted by email to info@aclboulder.org before I submit this form. If an ROI is not available at this time, I will send an email addressing my efforts to obtain one.

Yes, I have emailed a signed ROI or an explanation of my efforts to obtain an ROI to info@aclboulder.org.

Advocacy Eligibility: Adults in Boulder or Broomfield Counties who meet the Colorado definition of an intellectual developmental disability (C.R.S. 25.5-10-202) are determined eligible through a Community Centered Board (CCB). If the person has not already been found eligible, contact Imagine! at (303) 665-7789 and inquire about a letter of eligibility.

Does the person you are referring live in either Boulder or Broomfield County?

Yes, Boulder County

Yes, Broomfield County

Does the person you are referring have an intellectual developmental disability?

Yes

Not yet determined

Is the person you are referring enrolled with a CCB?

Yes

In progress

If yes, please list the CCB.

What is the person's case manager's name?

Referral Information: The most important part of the referral & intake process is that the person is seeking advocacy and support for themselves. Seeking advocacy is a personal decision and one that the person should be involved in making. Please involve the person in this referral process as much as possible. We acknowledge that there may be situations where it is not possible to fully include the person in this process, for example, when the person is incarcerated.

Please provide at least one method to contact the person directly.

The person I am referring to the ACL for advocacy is:

The person I am referring is currently incarcerated.

Yes

Advocacy Request For:

First Name

Last Name

Pronouns

Please tell us the words, language, and/or pronouns the person uses to describe themselves.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

(###)

###

####

Email Address

What is the person's primary language?

English

Spanish

Other (please note below)

Communication Support: If the person being referred needs support to communicate with us (ie: guardian or support staff to assist, video call, ASL interpreter, Spanish speaking advocate, etc) please describe here.

Please tell us about the situation for which the person is requesting advocacy. If you are not sure if the situation or issue falls into ACL's Scope of Advocacy, please see the Referral Guide linked at the top of this page.

Demographic Information: The ACL does not charge fees for services, so in order to keep our doors open, we apply for funding from various sources. These funders require us to report on the demographics (ethnicity, zip code, age, etc.) of the people we serve. Without this funding, the ACL would be unable to provide our current level of advocacy, support, and training. We understand that demographic information is sensitive, and we assure you no specific information is shared about the person or any member of their family. All information is used for program planning and evaluation. The information reported to funders is separated from any identifying information. It is totaled to show the overall impact of the work we do. This information will not affect any advocacy the person will receive. Thank you for your assistance in our efforts to continue to provide advocacy, support, and education free of charge.

Date of Birth

YYYY

Race and Ethnicity

White

Asian

Hispanic or Latino

Black or African American

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Mixed Race or other

How many people live in the person's household, including the person you are referring?

Requesting Professional's Information: You are making this request as a representative of a PASA/Service Provider Agency, CCB, Case Management/Care Coordination agency, or community organization. Please provide your business contact information:

Your Name

First Name

Last Name

Your Phone

(###)

###

####

Your Email

Relationship

Case Manager

Case Management Supervisor

Disability Service Provider

Community Service Provider

The information you have provided here will help us proceed in determining if the situation meets the criteria for direct advocacy. Our Intake Coordinator will contact you and/or the person you are referring after reviewing the information above to inform them of our decision. Please note that not all advocacy requests are eligible.

I understand that this is only a request for advocacy and submitting this form does not guarantee advocacy. I understand that not all advocacy requests are eligible.

Thank you. We appreciate you taking the time to complete this form thoughtfully.

Your request for Adult Direct Advocacy has been submitted.

If you haven’t done so already, please email the necessary Release of Information (ROI) to info@aclboulder now, so we can proceed with your advocacy request.

Click here to return to our homepage.

Adult Advocacy Request Form

—for Service Providers & Case Managers—

Stop here: Please review the referral guide before proceeding.