New Client Intake Form

First Name *

Last Name *

Email *

Address *

City *

State *

Postal code *

Phone *

How many children are you seeking services for? *

How are you related to the child ? *

First name of child *

Birthdate of child *

Child's school district

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.

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

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.

You understand that, in order to receive advocacy services at the reduced rate of $35/hour for Bronze services & $60/hour for Silver services, you MUST purchase a corresponding membership PRIOR to any services being rendered. If a membership is NOT purchased, ALL advocacy services will be billed at $125/hour *

Yes

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

The documents that will be helpful to review include:
- current IEP or 504 plan
- previous IEP if concern is related to changes
- last comprehensive evaluation report by the school
- any private evaluation reports of importance
- behavior/incident reports
- behavior plan/functional behavior assessment
- copy or forward of emails, prior written notices that you think would be helpful
- parent input/concerns(anything you think would be helpful for us to know).

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