We Speak New Client Intake Form
First Name
Last Name
Email
Phone Number
Address
Preferred method of communication
Email
Phone call
Text
Best time of day for phone calls?
What school district are you in?
What is your child's first and last name?
What is your child's date of birth?
What grade is your child in?
Child's race?
Child's gender?
Who does the child live with?
What (if established) is/are your child's qualifying diagnoses?
Autism
Deaf-blindness
Deafness
Emotional disturbance/disability
Hearing impairment
Intellectual disability
Multiple disabilities
Orthopedic impairment
Other health impairment (OHI)
Specific learning disability
Speech or language impairment
Traumatic brain injury
Visual impairment
Developmental delay
Undiagnosed
Does your child have any of the following?
Individualized Education Program (IEP)
504 Plan
Individualized Family Service Plan (IFSP)
None of the above
Does your child receive any related services?
Counseling
Interpretation services
Occupational therapy
Physical therapy
School nurse services
Speech therapy
Transportation
Other
None of the above
What is the date of your last IEP/504 meeting?
What is the date of your child's last evaluations?
Please describe your child's current educational placement. Are they in general education all day, a self-contained special education classroom all day, or somewhere in between?
Please describe any community based services your child receives (ie speech, OT, ABA, etc.)
Tell me about your child's strengths, anything about their behavior, personality, talents, habits, etc that you just love about them. This is where you can also share their interests with me.
Tell me a little bit about your goals for your child, both in this school year and when they age out of school.
Tell me about your child's needs and what you think would help them be successful in school and the community.
Please describe any behavioral concerns you may have. If you have none, please state 'none.'
Has disciplinary action ever been taken against your child?
Yes
No
What are the main reasons you are seeking advocacy? What is your top priority?
Have you ever filed a complaint to the state or the Office of Civil Rights (OCR)?
Yes
No
Have you worked with an advocate (or special education attorney) in the past?
Yes
No
Are you now or have you ever been involved in mediation, due process, or a settlement agreement?
Yes
No
How did you hear about me?
Personal recommendation
Google
Other search engine
Facebook
Instagram
Blog
Website
Other
Yes! Please send me your monthly-ish letters!
I affirm that I am the child's parent/guardian and have the right to make educational decisions.
Yes
No
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