HIB Questionnaire

This simple intake questionnaire will help us prepare for our first meeting. Although each education matter is unique, there is certain information which must be obtained at the initial consultation. Therefore, please answer the following questions as carefully as possible.

Date of Consultation

Provide Date

Please provide information regarding the child's guardian(s).

Parent 1 Name(Required)

First Last

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone Number(Required)

Parent 1 Cell Phone Number(Required)

Parent 1 Work Phone Number(Required)

Parent 1 Email(Required)

Enter Email Confirm Email

Parent 1 Relationship to child(Required)

Parent 2 Name(Required)

First Last

Birth Date(Required)

Parent 2 Cell Phone Number(Required)

Parent 2 Work Phone Number(Required)

Parent 2 Email(Required)

Enter Email Confirm Email

Parent 2 Relationship to child(Required)

Are parents married or divorced?(Required)

Please provide the following information about your child.

Full Legal Name(Required)

Birth Date(Required)

School District(Required)

Name of School(Required)

Does your child have an IEP?(Required)

Does your child have a 504 Plan?(Required)

If so, set forth the underlying disabling condition:(Required)

Present Classification(Required)

Current School Grade(Required)

Current Educational Program(s)(Required)

ex.: resource room, self-contained class, mainstreamed, out-of-district placement, etc.

Child is currently taking short-term or long-term medications.(Required)

Names and Purposes of Medications(Required)

About Your Child's Environment

Briefly describe any problems your child encounters at school(Required)

Briefly describe any problems your child encounters at home(Required)

Briefly describe any problems your child encounters in your community(Required)

I believe my child has been the victim of harassment, intimidation or bullying (HIB).(Required)

Please briefly describe.(Required)

HIB

Describe the nature of the current HIB(Required)

Have you or your school district filed a HIB complaint regarding the current issue?(Required)

Was there a HIB finding against your child regarding the current issue?(Required)

Did you request an appeal hearing?(Required)

Did you attend an appeal hearing before the board of education?(Required)

What was the outcome of the Board Meeting?(Required)

Have you requested and/or been provided with a copy of the HIB investigation records?(Required)

Do you have a trust/will?

Do you have a Special Needs Trust?(Required)

A Supplemental Needs Trust (sometimes called a Special Needs Trust) is a specialized legal document designed to benefit an individual who has a disability. Established to Preserve Governmental Benefits And Protect Assets. Please check below.

Do you have a Will?(Required)

A will is one of the most important estate planning documents you can have as it protects your assets and those of your loved ones. You should review an update your Will to reflect changes in your life such as marriages, the birth of a child, death, changes of financial status or revisions of estate laws in New Jersey.

Who referred you?

We'd love to know — how were you referred to us?(Required)

ex.: a friend's recommendation, our website, etc.

End of Special/General Education Questionnaire

Enter your email to complete this form.(Required)

Thank you for completing the Special/General Education Questionnaire. If you don't receive confirmation in your email, please check your junk mail.

Please remember to bring copies of the following to your consultation:

504 Plan
All communications regarding underlying HIB matter
Disciplinary notices
Current IEP
Past IEP
Testing completed by the District (including but not limited to): Psychological, educational, social, speech, occupational therapy testing
Progress Reports
Reports by private professionals (including but not limited to): medical doctors, psychiatrists, psychologists, developmental pediatricians, speech therapists, occupational therapists, physical therapists, neurologists
Notices from the District regarding any matter related to your child
Notices from public agencies – including the Department of Education or Truancy departments concerning any matters related to your child
Letters/Documents sent by you to the District

Please note that we will not keep any documentation you provide unless you decide to retain us, in which case, we will request copies of said documentation.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.



Contact us now

For a Private Consultation



SPECIAL NEEDS

SPECIAL EDUCATION

SPECIAL NEEDS TRUST

GUARDIANSHIP

LEARN MORE

BROCHURE



Estate Planning

WILLS & TESTAMENTS

ESTATE LITIGATION

TRUSTS & ESTATE PLANNING

LEARN MORE

BROCHURE

This simple intake questionnaire will help us prepare for our first meeting. Although each education matter is unique, there is certain information which must be obtained at the initial consultation. Therefore, please answer the following questions as carefully as possible.

Date of Consultation

Please provide information regarding the child's guardian(s).

Please provide the following information about your child.

About Your Child's Environment

HIB

Do you have a trust/will?

Who referred you?

End of Special/General Education Questionnaire

Please remember to bring copies of the following to your consultation:

Contact us now

For a Private Consultation

SPECIAL NEEDS

Estate Planning

SITEMAP

RESOURCE LINKS