Individuals who have obtained an appointment for an initial consultation may submit their client information in advance of their appointment, by filling out and submiting the following information. This form is specifially designed for individuals, who are seeking assistance for children with disabilities in public school. Individuals seeking different services may disregard irrelevant questions.
Client Mailing Address
Street & Apt #
City, State, Zip Code
Spouse's Name
Information on Child requiring services
Telephone, Fax & Email Information
Telephone # Cell Phone #
Fax #Email Address
Child's Name
Date of Birth Age Grade
Child's Disability: This portion of the form is intended to provide the maximum amount of information possible on your child and his/her disabilitiy. We are sensitive to the fact that your child is a unique individual and our purpose is not to categorize or label your child. In your initial consultation, we will ask many more questions, in order to have a full understanding of your child.
School District (County)
School Name
District Contact Person:
Highest ranked Individual you have spoke with about your issues
NameTelephone #
Primary Disability
Secondary Disability
Other
Other
Additional Description of the Child's Disability
Educational Documentation and Evaluations
Date of most recent IEP
Date scheduled for next IEP
Evaluations: Please check which of the following evaluations have been done on your child and indicate in the box next to the checked evaluation was done.
Date
Date
Date
Date
Date
Date
Other Evaluation
Date
Intellectual Level (I.Q.)
Services presently being provided: Please check which of the following services are presently being provided to your child by the school district. Next to the service indicate the amount of time per week your child is receiving each service.
Time
Time
Time
Time.
Areas of Concern and Issue with School: Please check which of the following areas are concerns or issues, which you would like to see addressed.
Statement of Issues: Please provide a statement of the principle issues that you wish addressed.
Individuals who have obtained an appointment for an initial consultation may submit their client information in advance of their appointment, by filling out and submiting the following information. This form is specifially designed for individuals, who are seeking assistance for children with disabilities in public school. Individuals seeking different services may disregard irrelevant questions.