AJE Request for Assistance Form

AJE Request for Assistance Form

Please complete the form below, and one of our staff will be in touch with you within 1-2 business days.

If you are referring a parent/family, you must indicate the parent's consent to the referral. Note, as a parent empowerment organization, families must decide to engage with us.

Fields marked with an asterisk (*) are required.

Your Contact Information

First Name

Last Name

Email

Phone Type

MobileHomeWork

Mobile

Home

Work

Mailing Street

Mailing City

Mailing State

Mailing Zip

Ward

Are you a

Parent/Guardian/CaregiverIndividual with a disabilityProfessional with an Agency/OrganizationOther

How can we help?

I am contacting you about

Accessing school (discipline, enrollment, etc)Behavior questions/issuesLearning questions/issuesWorking with my school/accessing my rights at schoolHealthcare-related questions/issues

Age of the person you are contacting us about

Have you worked with AJE-DC before?

YesNo

If a referral, did the parent provide consent to the referral?

YesNoN/A

Please provide any additional information that would be helpful (100 word limit)

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