Special Needs Intake Form

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Please note this is an interest form. In order for your child to be on a waiting list they have to qualify for a Special Class Integrated Setting ( SCIS ) thru the committee of Preschool Special Education within your School District. Our waiting list will be kept the order in which your child goes through committee and qualifies for a SCIS. Please complete the information below and Emily Vercelloni LMSW will be in contact with you.

Child's Last Name, First Name *

Child's Date of Birth *

YYYY

Child's Gender *

Female

Male

Prefer not to say

Other:

Parents Name *

Parents Address *

Parent's Telephone Numbers *

Parent's Email

School District the Child Resides in *

Current Services your Child Receives

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