DAS Parent Questionnaire

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Parent/caregiver survey to be filled out prior to first consultation

Email *

How did you hear about DAS? If referred, by whom? *

Parent/caregiver name *

Parent Address *

Parent contact information (phone) *

Student name *

Student age and grade level *

School District/School *

Disability - check all that apply *

Autism (ASD)

Learning Disability (auditory, visual processing delays, dyslexia) (SLD)

Speech and language impairment (SLI)

Other Health Impairment (OHI) (ADHD, ADD)

Emotional Disturbance (ED)

Visual or hearing impairment

Intellectual Disability, including Down Syndrome (ID)

Multiple Disabilities

OI (Orthopedic Impairment)

TBI (Traumatic Brain Injury)

Required

Does your child already have a 504 plan or IEP *

IEP

504

Required

What are your primary concerns related to? *

My child is not receiving services promised

My child doesn't have access to their accommodations in the classroom

The IEP/504 team is dismissive about my concerns

I want someone to attend meetings with me

I need help understanding all the paperwork and process

I want someone to make recommendations about services that would help my child

My child was denied services

Required

Please briefly explain any other concerns not listed above *

Submit

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