Intake Form

Parent or Guardian Information

First Name (First Parent or Guardian)

First parent or guardian

Last Name

First parent or guardian

Legal Name (If different than First Name)

Email Address (First parent or guardian)

Confirm Email Address (First parent or guardian)

Confirm Email

First Name (Second Parent or Guardian)

Second parent or guardian

Last Name

Second parent or guardian

Legal Name (If different than first name)

Email Address (Second parent or guardian)

For your privacy protection, usually a personal email is better than a work email.

Which of the following best explains your relationship to the student?

Parent

Guardian

Conservator

Other

Address

City

State/Province

Zip/Postal

Phone Number

Student Information

Student's First and Last Name

Date of Birth

Grade

Student's Photo

If you have a digital photo available, we appreciate your uploading it here. It is really nice to see the student and remind ourselves who the most important person is in this case.

File Upload (May upload multiple files)

Maximum upload size: 104.86MB

Who should we correspond with?

Mother, father, both, other

Diagnosed Disability

Custody Arrangement

Married, divorced, other

Does Your Child Have an IEP?

Yes

No

If Yes, What Eligibility Categories Do They Qualify Under?

School Name

School District

Who has the "educational rights" to act on behalf of the student? Check all that apply.

Name, if known, of district special education director

Are you a regional center consumer? If so, which group?

Brief summary of struggles with your district

Are you currently paying for services out of pocket? If yes, please explain

Do you have a family history of any genetic illnesses, chronic health problems, learning disabilities, attention deficit disorder, or other relevant diseases? Please List

How did you hear about us?

Referral from friend, teacher, neighbor, etc.

Internet search

OtherOther

Please tell us who filled out this form

Parent

Guardian

Conservator

OtherOther

Any other details you would like to share?

IEP and Other Documents

If you have documents such as an IEP in a digital format, please upload them here.

File Upload (May upload multiple files)

Maximum upload size: 104.86MB

If you heard of us from a referral, please let us know who that is. We love to thank people.

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