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. We offer a free, 30-45 minute consult call for all families completing this form for the first time.

Please note that completion of this form does not guarantee that 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 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). *
Given what you shared about your child, what is the most pressing issue you that you wish to address by hiring an advocate? It is also okay to be unsure. We understand that you might feel overwhelmed and need help from us to prioritize. *
Child Name *
Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Grade *
School Name *
ID Number OSIS
School District Number *
CSE Number *
Part 2: Parent Contact Information
Parent Name 1 *
Parent 1 Mailing Address *
Parent 1 Email Address *
Parent 1 Phone Number *
Parent Name 2
Parent 2 Mailing Address
Parent 2 Email Address
Parent 2 Phone Number
Child Resides with
Clear selection
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