Family Intake Form

Today's Date

Were you referred to one of our attorneys?
 yes no

Which Attorney?
Bonnie YatesElizabeth Eubanks

Mother's First and Last Name

Father's First and Last Name

Child's First and Last Name)

Child's Age and Date of Birth

What are some of your initial concerns?
 IEP Meeting Regional Center Eligibility IPP Meeting Appropriate Services

Eligibility or Learning Disability or Diagnosis

What remedy are you looking for your child?

Your Child's School

School Presently Attending

School District

Last IEP Date

Did You Sign?
 yes no

If not, was a dissent filed?
 yes no

Is your child eligible for Regional Center Services?
 Yes No

If yes, what Regional Center?

If yes, what services?

Has your child recently been assessed by private assessors?
 Yes No

If yes, when and whom?

Do you have a mediation scheduled?
 Yes No

If yes, when?

Do you have a Due Process Hearing scheduled?
 Yes No

If yes, when?

Do you currently fund private services? ABA, LAS OT, PT
 None ABA LAS OT PT

If yes, how many hours per week?

Has your family ever been represented by an advocate
or attorney before in an educational proceeding?
 Yes No

If yes, whom?

Please note: It is very important that you provide us
with complete contact information.

Family

Family's Home Address

Home Telephone

Home Fax Number (if applicable)

Mother

Cell Phone Number

Email

Employer

Your employer will not be contacted.

Job Title

Work Number

Work Fax (if applicable)

Address of Employer

Father

Cell Phone Number

Email

Employer

Your employer will not be contacted.

Job Title

Work Number

Work Fax (if applicable)

Address of Employer

How did you hear about us?

Be sure to complete the 4 digit code above before submitting

For your privacy, this information will be used for consultation
and evaluation purposes only and will not be shared
with any other persons or organizations.