Contact Information
Intake Form for consideration of Services from SpEdConnecticut, Inc.
Name - Mother: *
Your answer
Name - Father: *
Your answer
Child's Name: *
Your answer
Child's Date of Birth: *
Please be sure to include the year. MM/DD/YYYY
MM
/
DD
/
YYYY
Email - Mother: *
Your answer
Email - Father: *
Your answer
Child's Address - Primary: *
Please include town and zip code
Your answer
Phone number - Mother: *
Your answer
Phone number - Father: *
Your answer
Employer - Mother: *
Name and address of Mother's employer
Your answer
Employer - Father: *
Name and address of Father's employer
Your answer
Who referred you to SpEdConnecticut?
Your answer
Grade of Child: *
Your answer
Has your school completed evaluations for your child?
Does your child have an IEP? *
Required
Do you have complete set of records for your child (from a written request for a copy of your child's records)?
Primary Disability *
This can be found on the IEP first page under Primary Disability ( if your child does not have an IEP skip to next question)
Required
Does your child have a 504 plan? *
Required
If yes, what is the purpose of the 504 plan?
Your answer
School District: *
Your answer
School Name and Address: *
Your answer
Primary Reason for your Interest in SpEdConnecticut: *
Please describe briefly the problem you are having and what your desired outcome would be.
Your answer
Annual Household Income: *
Providing this information is helpful in determining your hourly rate. If you do not wish to disclose household income, you will be charged the full rate $90 an hour.
Required
Number of People living in the home: *
Number of dependents *
Income Verification *
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