Special Support Services: Parent Intake Form
All information is kept confidential between the individual completing the form and Special Support Services. Completing this form helps us understand your needs and what you want to achieve for your child. Please note that completion of this form does not guarantee we can support you as a client.

About Special Support Services: https://specialsupportservices.com

This form takes about 30 minutes to complete. In order to best process our your information, we do require the email address of the person completing the form.

Email address *
CONTACT INFORMATION
PART 1: About Your Child & Any Current Issues
Tell us about your child and any current issues that your child is having in school or in the community (i.e., bullying, IEP issues or problems with services). *
Your answer
Child Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Your answer
Grade *
Your answer
School Name *
Your answer
ID Number OSIS
Your answer
School District Number *
Your answer
CSE Number *
Your answer
Part 2: Parent Contact Information
Parent Name 1 *
Your answer
Parent 1 Mailing Address *
Your answer
Parent 1 Email Address *
Your answer
Parent 1 Phone Number *
Your answer
Parent Name 2
Your answer
Parent 2 Mailing Address
Your answer
Parent 2 Email Address
Your answer
Parent 2 Phone Number
Your answer
Child Resides with
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