Intake Form

Parent or Guardian Information

First Name

First parent or guardian

Last Name

First parent or guardian

Legal Name (If different than First Name)

Email Address (First parent or guardian)

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

First Name

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

Country

Phone Number

Student Information

Student's First and Last Name

Date of Birth

Grade

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?

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

School Name

School District

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)

Drop a file here or click to upload Choose File

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

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Intake Form

Parent or Guardian Information

Student Information

IEP and Other Documents

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