Intake Form - Special Ed.

Note: Please provide ALL requested information. We cannot provide legal advice until you do so.

Preferred consultation type: *	----Phone ConsultationVideo Consultation
Skype username:
Child’s full name: *
Child’s date of birth: *
Mother’s full name: *
Father's full name: *
Family’s home street address: *
Family’s city, state & zip: *
Home telephone number: *
Home fax number (if applicable):
Mother's cell phone: *
Mother's Email address: *
Name of Mother's employer: *
Employer's Address *
Mother's Job title: *
Mother's Work number: *
Mother's Work Fax (if applicable):
Father's cell phone number: *
Father's Email Address: *
Father's Employer *
Employer Address: *
Father's Job Title: *
Father's Work number: *
Father's Fax number (if applicable):
What is your child's eligibility or learning disability or diagnosis? *
What school is your child presently attending? *
What school district is this school in? *
What is the date of your last IEP? *
Did you sign? If not, was a dissent filed? *
Is your child eligible for Regional Center services? If so, which Regional Center and what services? *
Has your child recently been assessed by private assessors? If so, when and by whom? *
Do you have a mediation scheduled? If so, when? *
Do you have a due process hearing scheduled? If so, when? *
Do you currently fund private services (ABA, LAS, OT, PT) for your child? If so, how many hours per week/month? *
Has your family ever been represented by an advocate or attorney before in an educational proceeding? If so, whom? *
What remedy are you looking for in this case? *
How did you hear about us? If referred, who referred you? *
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If you do not hear back from us within three business days, please call us at (310) 204-6624.

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