Basic Info
Parent’s Name:
Phone Number:
Email:
Home Address:
Best time/way to contact parent:
Student Name:
Student Age & Date of Birth:
School System or Charter Organization:
School:
Grade:
Is student currently in school?
Does student have an IEP or 504 plan?
Exceptionality/Exceptionalities:
Medical Diagnoses:
Referred by:
Primary Issue:
Educational History & General Information
How long has the student been at current school?
What other schools has the student attended? What were the years/grades of attendance and the reasons for leaving?
When did your child first start experiencing issues or problems at school?
How is your child currently doing at school?
What are your child’s strengths at school?
Please describe any issues or difficulties your child has had or is having at school.
Does your child have the same difficulties at home?
504 Plan
Does the student currently have a 504 plan?
Has the student ever previously had a 504 plan? If so, when did the student first obtain a 504 plan?
What disability is/was the 504 plan based on?
What accommodations and services does/did the student receive through the 504 plan?
Does the student actually receive the accommodations listed in the 504 plan?
Are there any additional accommodations or supports you would like for your child to receive?
Special Education Evaluation & Eligibility
Has the child ever been evaluated for special education services?
If so, when? Who asked for the evaluation and why? What was the result of the evaluation(s)?
When was your child’s most recent special education evaluation conducted?
Was there a meeting to go over the results of the evaluation?
Have you ever waived or been asked to waive a reevaluation?
What education records does the parent have available in hard copy or electronically?
Has the parent ever requested education records that have not been provided? Date?
Special Education & IEPs
When did your child first start receiving special education services?
When was your child’s last IEP meeting held?
Can you please describe the meeting? Who attended? How long did it last? Were you given an opportunity to ask questions? Did you have an opportunity to provide input as to what you wanted in the IEP?
How much of the day does your child spend in regular education versus special education classes?
What subjects does your child receive in a special education classroom?
What subjects and other school activities does your child receive with non-special education students?
Does your child receive any related services like speech or occupational therapy? If so, how many times a week or month and for how long?
What kind of accommodations does your child receive in the classroom?
Does your child use any assistive technology at school? If so, what kind of device(s) does your child use?
Medical & Mental Health Information
Does your child have any medical or mental health diagnoses? What are they?
When was your child first diagnosed?
Does your child take any medication? If so, what medication and dosages is your child prescribed?
Has your child previously been prescribed different medication? If so, when and why did it change?
Who does your child see for medical or mental health services? How often?
Does your child have Medicaid? Private insurance?
Discipline
Does your child have issues with behavior or discipline at school? If so, please describe.
Has a Functional Behavioral Assessment (“FBA”) ever been conducted for your child? If so, what were the target behaviors?
Does your child have a Behavior Support Plan or Behavior Intervention Plan (“BIP”)? If so, please describe.
Has your child had a Behavior Support Plan or Behavior Intervention Plan (“BIP”) in the past?
Has your child ever been suspended?
Has your child ever been recommended for expulsion?
Is your child frequently subject to other forms of discipline like a timeout room or loss of privileges?
Please describe the details of each incident resulting in a suspension (including informal removals and in-school suspensions) or recommendation for expulsion within the past year.
[Ask for each incident]:
Did you receive notice of the disciplinary action? When? Was it verbal, in writing, or both?
Was there a Manifestation Determination hearing (where IEP team meets to decide if behavior is related to the disability)? If so, when?
[For incidents leading to expulsion recommendation]: Was there an expulsion hearing? If so, when? What was the outcome?
Goals of Representation
Of all the problems and issues at school we have discussed, which do you think is the most important to address?
What kind of changes do you think would help your child at school?