Arizona Intake Form

ARIZONA INTAKE FORM

Upon submitting this intake form, if you do not receive a confirmation of submission email within 24 hours, please contact Ashely Dickerson (adickerson@youthlaw.org) for Maricopa County, Shane Carr (scarr@youthlaw.org) for Yavapai County, or Jennie Hedges (jhedges@youthlaw.org) for all Pima County and all other counties.

Please provide the following information:

Student's County:* Please select the county where this student is currently living.

Student's Legal First Name:*

Student's Legal Last Name:*

If this student goes by a preferred name, please list here:

Date of Birth:*

Gender Identity:*

Placement Address:*

City:*

Zip Code:*

Translation Support Requested

Placement Type:*

Is this student a parent (or have parenting or caregiving responsibilities)?*

Placement Contact Name:*

Placement Email:

Placement Phone:

Behavioral Health Provider:

Care Coordinator:

Care Coordinator Email:

This student is currently on probation, or juvenile justice system(s) involved

Education

Current School:*

Grade:*

Education Rights Holder:

School of Origin (if different than current school):

Student's Strengths:*
Please check all that apply (to select multiple values, hold the Command/Control key)

Educational Concerns:*
Select all that require FosterEd responsive services and briefly describe each selected concern below (to select multiple values, hold the Command/Control key)

Please describe selected concerns:*

Please provide your contact information

Submitted by First Name:*

Submitted by Last Name:*

Submitted by Email:*

Submitted by Phone:*

Specialist Type:*

Office Address:*

Additional Notes: