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Newman Aaronson Vanaman - Special Education Advocates and Attorneys

 
Client Intake Form
In order to serve you better, please take time to fill out our client intake form. When you click the submit button, the form will be sent to one of our lawyers for review. We'll contact you soon regarding your case.

Parent Information
Email: (*)
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First Name:
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Last Name:
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Street Address:
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City:
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Zip:
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Home phone:
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Work phone:
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Cell phone:
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Do you require an interpreter?
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School Information
School:
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District:
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Student Information
Student's First Name:
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Student's Last Name:
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Birthdate (mm/dd/yyyy):
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Grade:
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Is the student currently in Special Ed.?:
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What is the student's disability?:
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Receiving district services?:
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If you selected yes, indicate the services received and the frequency (e.g. - 1x per wk for 1 hour)
Occupational Therapy (OT):
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Physical Therapy (PT):
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Assistive Technology (AT):
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Vision Therapy (VT):
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Deaf & Hard of Hearing (DHH):
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Language & Speech (L&S):
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Adaptive Physical Therapy (APT):
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Other:
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What are the current problems you are having with the District/Regional Center?
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What services do you want our office to obtain for you?:
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Additional Information
Has there been a private assessment?:
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If yes, who gave the assessment?
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What was the date?
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Has there been a district assessment?:
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What was the date?:
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Have you had an IEP?:
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Date of most current IEP:
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Have you ever been represented by and advocate or attorney?
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Name of advocate or attorney:
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Are they currently providing you with services?:
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Comments:
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