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- Intake Form

Intake Form

Please take a few moments to fill out our intake form. This information is extremely helpful to better understand your unique needs and situation.

Intake

Parent or Guardian Information

First Name

First parent or guardian

Last Name

First parent or guardian

First Name

Second parent or guardian

Last Name

Second parent or guardian

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

Parent

Guardian

Conservator

Other

Email Address

Address

City

State/Province

Zip/Postal

Country

Phone Number

Student Information

Student Name *

Date of Birth

Grade

Who should we correspond with?

Mother, father, both, other

Diagnosed Disability

Custody Arrangement

Married, divorced, other

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

Mother

Father

Guardian

Conservator

Other

School District

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.

Website

Other

Please tell us who filled out this form *

Parent

Guardian

Conservator

Other

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

Uploading Files. Please Wait.

Drop a file here or click to upload Choose File

Maximum upload size: 67.11MB

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