Client Intake Form

Special Education Ally Advocacy & Mediation

Thank you for reaching out to Special Education Ally Advocacy & Mediation. Please complete this form to help us understand your child’s needs and how we can best support you.

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Parent/Guardian Information

Full Name:

First

Last

Phone:

Email:

Address:

Address Line 1

City

State

Zip Code

Student Information

all specific disability?

Full Name:

First

Last

Date of Birth (DOB):

Age:

School Name:

Grade Level:

School District:

Educational Support & Services

Is the student receiving Special Education services?

Does the student have a 504 Plan?

Has the student been formally diagnosed with a disability?

What services is the student currently receiving? ? (Check all that apply)

Concerns & Challenges

What specific challenges or issues are you and your child experiencing with the school?

Have there been any past meetings or discussions with the school regarding these concerns?

What outcomes are you hoping to achieve through special education Ally support?

How Can We Support You?

What type of support do you need? (Check all that apply)

Assistance with IEP or 504 Plan Development
Attending School Meetings (IEP, 504, Mediation)
Understanding Your Child’s Educational Rights
Filing Complaints or Due Process Hearings
Behavioral & Academic Support Strategies
Other

Additional Information

Is there any other important information we should know about your child’s situation?

Parent/Guardian Consent

I confirm that the above information is accurate to the best of my knowledge. I understand that Special Education Ally Advocacy & Mediation will use this information to provide advocacy services and support.

Date:

Parent/Guardian Signature:

Clear Signature

Client Intake Form

Special Education Ally Advocacy & Mediation