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.

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

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)

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)

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.