Existing Client Intake

Parent Name

First Name *

Last Name *

Email *

Address (if different)

Address

City

State

Zip code

Phone *

Any siblings we have helped?

Current Child

First name of child

What is your relationship to the child?

Biological Parent
Adoptive Parent
Legal Guardian
Surrogate Parent
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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?

Yes

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)

IEP

504

FBA

BIP

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?

Yes

How is your relationship with the school?

Please check any Parental Concerns you have in the following areas:

Reading

Spelling

Writing

Handwriting

Math

Behavior

Social Skills

Forming Friendships

Emotional Regulation

Speech

Language

Transitions Between Activities

Vocations (Post High School)

Vision

Hearing

Fine Motor Skills

Activities for Daily Living

Extracurricular Activities / Leisure Skills

Community Living

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!

Yes

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.

Yes

Please upload any files you feel are relevant to your situation.