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*Contact email address:

*Child's Name:

*DOB:

*Mother's Name:

*Father's Name:

*Eligibility or learning disability or diagnosis:

*School presently attending:

*School District:

*Last IEP Date:

*Did you sign?

*If not, was a dissent filed:

*Is child eligible for Regional Center Services?

*If so, which Regional Center:

*If so, What Services:

*Has child recently been assessed by private assessors?

*If so, when and whom:

*Do you have a mediation schedule?

*If so, when:

*Do you have a dues process hearing schedule?

*If so, when:

*Do you currently fund private services (ABA, LAS, OT, PT) for your child?

*If so, how many hours per week:

*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?

Family's home address:

Home telephone number:

Home Fax number (if applicable)

Mother's cell phone number:

Mother's email address:

Father's cell phone number:

Father's email address:

Mother's Employment:

Job Title:

Name of business:

Address of employer:

Mother's work number:

Mother's work fax (if applicable)

Father's employment:

Job title:

Name of business:

Address of employer:

Father's work number:

Father's work fax (if applicable)

How did you hear about us?