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Special Education Questionnaire

Sussan, Greenwald & Wesler > Special Education 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.

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Date of Consultation

Provide Date

Date Unknown

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Do you have a trust/will?

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 Special Needs Trust?

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.

Do you have a Will?

Would you like more information about creating a Will?

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

Parent 1 Name

Parent 2 Name

Address

City

State

Zip Code

Home Phone Number

Parent 1 Cell Phone Number

Parent 1 Work Phone Number

Parent 1 Email Address

Parent 1 Relationship to child

Parent 2 Cell Phone Number

Parent 2 Business Phone Number

Parent 2 Email Address

Parent 2 Relationship to child

Add second address

Parent 2 Address

Parent 2 City

Parent 2 State

Parent 2 Zip Code

Are parents married or divorced?

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Who referred you?

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

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

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Please provide the following information about your child.

Full Legal Name

Birth Date

School District

Name of School

Present Classification

Current School Grade

Current Educational Program(s)

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

Child is currently taking short-term or long-term medications.

Names and Purposes of Medications

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About Your Child's Environment

Briefly describe any problems your child encounters at school

Briefly describe any problems your child encounters at home

Briefly describe any problems your child encounters in your community

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

Please briefly describe.

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About Your Child's Environment

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End of Special/General Education Questionnaire

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

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