Request for adult Advocacy

Advocacy may be requested for:

Adults in Boulder or Broomfield Counties who meet the Colorado definition of an intellectual/developmental disability (C.R.S. 25.5-10-202) as determined through a Community Centered Board (CCB). If a person does not already meet this definition, advocacy is limited to assisting them to access eligibility determination through the CCB and/or possible referral to other community resources.

Advocacy Requested for:  

Do you or the person you are referring have a developmental disability?
Advocacy Request For: *
Advocacy Request For:
Date of Birth
Date of Birth
Address
Address
Phone number
Phone number
Are you currently working with Imagine!?
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 you or any member of your family. All information is used for program planning and evaluation, and information reported to funders is separated from any identifying information, then totaled to show the impact of the work we do. This information will not affect any services you receive. Thank you for your assistance in our efforts to continue to provide advocacy, support, and education free of charge.
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Ethnicity
If you are making the referral for someone else, please fill out the following:
Your Name
Your Name
Your Phone
Your Phone
Your Address
Your Address
Relationship