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Request A Consultation
In-Take Form
Please complete this form before scheduling a consultation so that I may better understand your child’s educational situation.
Parent(s) Name
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Phone Number
Fax Number
Email
Child's Name
Child's D.O.B.
School District
Diagnosis / Disability
Classification
Have you had any evaluations by the Child Study Team?
*
Required
No
Yes
If yes upload here
Upload supported file (Max 15MB)
Have you had any private evaluations:
*
Required
No
Yes
If yes upload here
Upload supported file (Max 15MB)
What type of placement is your child now in? Please select
Self Contained – MD, LD
Pull out replacement
Autistic Program
In-class support
Out of District
Early Intervention
Other
Full Day
Half Day
Does your child receive an Extended School Year?
*
Required
No
Yes
Are you satisfied with your child’s educational program?
*
Required
No
Yes
Has a mediation request or due process petition already been filed?
*
Required
Yes
No
If "Yes" please explain
Are there any upcoming meetings scheduled with the school district?
*
Required
Yes
No
If "Yes" please provide the date and type of meeting (IEP, eligibility meeting, mediation, etc.)
Do you currently have a deadline approaching (such as a mediation filing deadline)?
*
Required
Yes
No
If "Yes" please provide date
Referred by:
Thanks for submitting!
Submit
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