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Consent Agreement

Individuals who have obtained an appointment for an initial consultation may submit their client information in advance of their appointment, by filling out and submitting the following information. This form is specifically designed for individuals, who are seeking assistance for children with disabilities in public school. Individuals seeking different services may disregard irrelevant questions.
Consent(Required)

First, tell us more about yourself.

What should we call you?
Your Name(Required)

Nice to meet you!

And what would be the best way to contact you?
Preferred Contact(Required)
Select all that apply

What's your address?

Your current mailing address will be fine.
Address

Do you have a spouse, or significant other you would consider a co-parent?

Anyone who would potentially need to be kept in informed.
Yes or No(Required)
Spouse or Co-Parent's Name
Does your co-parent live with you?
Co-parent's Address

Now, tell us about your child.

Child's Name(Required)
Date of Birth(Required)
Untitled

And what school do they currently attend?

Have you spoken to anyone at your child's school about these issues?

Highest ranked Individual you have spoken with about your issues.
Name

Child's Disability:

This portion of the form is intended to provide the maximum amount of information possible on your child and his/her disability. We are sensitive to the fact that your child is a unique individual and our purpose is not to categorize or label your child. In your initial consultation, we will ask many more questions, in order to have a full understanding of your child.

Educational Documentation and Evaluations

Date of most recent IEP
Date scheduled for next IEP
Evaluations
Please indicate which of the following evaluation services have been done for your child.

Services your Child is Currently Receiving

Please check which of the following services are presently being provided to your child by the school district. Next to the service indicate the amount of time, per week, your child is receiving each service. If you're not sure, you may skip this section.

Areas of Concern and Issue with School

Please check which of the following areas are concerns or issues, which you would like to see addressed.
Select All that Apply
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