Michael J. Eig & Associates, P.C. - Intake Form
You simply have to fill out the provided form, submit it to us and we will respond shortly.
AOL Users can click here for a PDF Version of the Intake Form |
| Atty Requested: |
|
Referred by: |
|
Date: |
|
| Taken By: |
|
Child's Name: |
|
Date of Birth: |
|
| Adopted? If so, at what age/place of birth? |
|
| Parents/Guardians: |
|
| Marital status of parents: |
|
| Home Address: |
|
| Are you currently working with an attorney or Educational Advocate? If so, whom,
and how/when was the relationship terminated?: |
|
| Have you worked with an attorney or Educational Advocate within the last 2 to 3 years? If so, whom, and how/when was the relationship terminated?: |
|
| Local Education Agency (School System):
|
|
| Contact Phone (home #, work #, cell): |
|
| Current Grade: |
|
| Current School: |
|
| Is the above the home/neighborhood school? If not, what is? |
|
| Ever repeated a grade? If so, what was reason? |
|
| Currently receiving special ed services? If so, since when? |
|
| Name and/or description of special education program: |
|
| Disability Code(s) / Diagnostic Label(s) |
|
| Is there an IEP in place? Does it include related services? If so, which related serices? What is the level / intensity of service? |
|
| Name and duration of previous educational placements (to extent known): |
|
| What are you seeking? If Private Placement,
what notice has been given to school system, and when?: |
|
| Why are you unhappy? |
|
| When and what was the most recent testing? Diagnosis? Name(s) of evaluator(s)? Recommendations?
|
|
| Any medications? If so, when did they start? |
|
| Any upcoming meetings scheduled with the county? When? Where? |
|
| Date/type/outcome of most recent meeting? |
|
| In what time frame would you like this to be resolved? |
|
| Any additional information? |
|
|