Education Intake Form

Reason For This Appointment

Your Name (required)

Your Address (required)

Your City (required)

Your State (required)

Your Zip (required)

Your County (required)

Your Email (required)

Home Telephone Number

Cell Telephone Number

Work Phone Number

Date of Birth

How Did You Hear About Us?

The Following Section is information for your child or children

Minor Child's Name

Child's DOB

Does your child have special needs
 No Yes

Minor Child's Name

Child's DOB

Does your child have special needs
 No Yes

Minor Child's Name

Child's DOB

Does your child have special needs
 No Yes

Minor Child's Name

Child's DOB

Does your child have special needs
 No Yes

Minor Child's Name

Child's DOB

Does your child have special needs
 No Yes

Current Grade level of Special Needs Child

Current School of Special Needs Child

School City and County

Current Education Plan

Date of Recent Special Education Meeting

Date of Most Upcoming Special Education Meeting

Most Recently Completed Testing (Please Include)

Most Important Issue with Current School Plan or School Recommendation

Check any Special Education Issues for Student
 Autism Language/Speech Disorder ADD/ADHD Specific Learning Disability Intellectual Disability Other Health Impairment Hearing Impaired Visual Impaired Anxiety Emotional Issues Behavior Issues Other/Not Listed

What is your ultimate goal for a resolution to the student’s issue?

Please list any current questions or issues you would like to make us aware of

**A Consultation Fee is required at the time of your appointment**

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