Intake Form

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.

Attorney Requested:
Referred by:
Date
MM slash DD slash YYYY
Child's Name:
First Last
Date of Birth:
MM slash DD slash YYYY
Adopted? If so, at what age/place of birth?
Parents/Guardians:
First Last
Marital status of parents:
Parents'/Guardians' Email Address:
Parents'/Guardians' Home Address:
Street Address City State / Province / Region ZIP / Postal Code
Parents'/Guardians' Contact Phone Numbers (home #, work #, cell):
Are you currently working with an attorney or Educational Advocate?
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?:
County School System:
Current School:
Is the above the home/neighborhood school? If not, what is?
Name and duration of previous schools attended:
Current Grade:
Ever repeated a grade? If so, what was reason?
Currently receiving special ed services? If so, since when and under what disability coding, if known?
Number of hours for services given under current IEP and in what setting are these services provided?:
Is there a Section 504 Plan in place? If so, what accomodations are being provided?
What brings you to contact our office? (Please be as detailed as possible.)
If you are seeking a private placement or have placed your child privately, what notice has been given to school system, and when?:
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? When? Where? What type of meeting? (i.e. IEP, mediation, hearing CIEP)
Date/type/outcome of most recent meeting?
Desired outcome of representation, if know:
Any additional information as to what you feel is going wrong, or needs to be addressed:
Would you like information/input about life planning (i.e. wills trusts, special needs planning, guardianships)?
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Intake Form

Michael J. Eig & Associates, P.C. - Intake Form

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