JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Intake Information
Please answer all question to the best of your ability. The information will be used to identify which of our services best fits your needs.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Parents Name
*
Your answer
What City and state does your child attend school
*
Your answer
Phone number
*
Your answer
Students Name
*
Your answer
Please select which disability your child has or you suspect him/her of having. Check as many that apply
*
ADHD ( other health impaired)
Autism Spectrum Disorder (ASD)
Down Syndrome.
Hearing Disorders
Intellectual Disabilities
Learning Disabilities ( Dyslexia Dysgraphia Dyscalculia)
Non-verbal
Non-Mobile
Seizure Disorders
Tourette Syndrome
Traumatic Brain Injury.
Visual Impaired
Mental Health disorder
Behavioral/Emotional
Speech and Language delays
Development Delays
Other:
Is your child currently receiving special education services?
*
Yes
No
Is your child currently getting services under a Section 504 ?
*
Yes
No
Which statement below best describes your current issues:
*
The School is not implementing IEP or 504 correctly
Your child continues to have trouble with academics even with the IEP or 504 plan
You requested evaluations for your child and the school said no
You suspect someone has been aggressive towards your child ( student comes home with marks, or bruises)
Your child continues to get suspended and/or behavioral referral even with the 504 or IEP?
Your child has been suspended or expelled from school
Your child has a 504 plan and you think your child needs an IEP
You are looking for guidance's about your child's special education services.
You want someone to review your child's IEP and provide feedback on its appropriateness
You a need a Coach to help you teach about your rights under special education
Other:
What happened to make you want to hire an Special Education Advocate
Your answer
What steps have you taking to get your concerns resolved by the IEP team or school personnel? What was the outcome of those efforts?
*
Your answer
List the outcomes you want from advocacy services? (ex. I want additional evaluations.)
*
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
