Educational Intake- Nassau County
Email address *
Child's Name *
Child's Date of Birth (MM/DD/YYYY) *
Your Name *
Are you the child's parent/legal guardian? *
Have you discussed this issue/concern with an attorney or an advocate not affiliated with the Long Island Advocacy Center? *
Street Address *
City or Town *
Zip Code *
Phone Number *
School district your child resides in *
Name of School your child attends *
What grade is your child in? *
Primary Concern *
Does your child have a disability? If yes, please include any diagnoses *
Does your child have a 504 Plan? *
If your child has an IEP, please let us know what the classification is *
Please briefly describe your main concerns *
Household Income? (Choose One) *
Number of people in household? *
Race:
Would you prefer we contact you via email or phone? *
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