Special Education Law Intake Form

Parent Name(s) *

Child's Name *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency contact name & relation

Emergency contact phone number

Type in "public school" or "private school" to indicate which system your child is in.

Name of public school and district or name of private school

Does your child have a diagnosed disability/IES? If so, please list.

Does the child hav an active 504 or IEP? If so, please list which one(s) and date (if known) of the most recent ones.

What is the problem or concern?

What solution do you seek?

Comment or message *

Name