Existing Client Intake
Address (if different)
Any siblings we have helped?
First name of child
What is your relationship to the child?
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Birthdate of child
Child's school district (if applicable)
Child's grade level
Is there a suspension, expulsion, or other disciplinary measures in place?
Does your child have any of the following? If so, please attach the information at the end of this document.
Initial Evaluation Report (MET, CST, or other)
Any private evaluations
Does the child have any outside (medical) diagnoses such as ADHD, ASD, ODD, OCD, PTSD, PANDAS, rare medical/genetic condition and/or etc?
Does your child take medication and/or recently started/changed medication?
How is your relationship with the school?
Please check any Parental Concerns you have in the following areas:
Transitions Between Activities
Vocations (Post High School)
Fine Motor Skills
Activities for Daily Living
Extracurricular Activities / Leisure Skills
Please explain the problems you are having with the issues you mentioned above.
Please explain why you are seeking educational advocacy assistance.
Please explain what outcome are you seeking.
By checking YES, you acknowledge that you will receive feedback forms from us and agree to fill them out promptly. This ensures that our program met your needs, as well as collect important data for our grant-funding requests. THANK YOU!
By selecting YES, you acknowledge that you understand PASEN is not a legal service and cannot practice law. The information and opinions of our parent-advocates are gained from our own experience and ongoing study of the special education process.
Please upload any files you feel are relevant to your situation.
.pdf, .docx, .doc, .xlsx, .xls, .csv