Unity Ed Resource/ Support Intake
Full Name of person filling out the form
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Preferred Method of Contact
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What type of support are you seeking?
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What type of support are you seeking?
Who is this support for?
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Full name of person needing services (if not the person filling out the form).
Have you already applied, appealed, or spoken with any agency about this issue?
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Have you already applied, appealed, or spoken with any agency about this issue?
If yes, please describe what has been done so far.
Have you received any letters, denials, or requests for information?
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Have you received any letters, denials, or requests for information?
If yes, please upload them below.
How urgent is your situation?
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How urgent is your situation?
What outcome or goal are you hoping to achieve with Unity Ed’s support?
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Relevant diagnoses, accommodations, or special needs
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Are there any agencies or professionals involved? Please list.
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Please provide any other information that you feel is relevant.
How did you hear about Unity Ed?
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How did you hear about Unity Ed?
Confidentiality and Consent: I understand that Unity Ed provides educational and advocacy support, not legal or medical advice.
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Confidentiality and Consent: I understand that my information will be kept private and only used for case coordination.
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I understand that Unity Ed may request further information or documents to assist me
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Please sign confirming request for contact from Unity Ed
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