Michael J. Eig & Associates, P.C. - Intake Form
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Atty Requested:
Referred by:
Date:
Child's Name:
Date of Birth:
Email Address:
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?