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East County SELPA ADR Services Request
Please fill out this form to the best of your ability. If you are having difficulties completing this form you can call (858) 298 2214 or email
eastcoselpa@sdcoe.net
for assistance.
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* Indicates required question
Your name
*
Your answer
Name of the student
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Relationship to the student
*
Parent/ Guardian
School District
Other
Primary Language Parent/ Guardian
Your answer
What is the best phone number to reach you?
*
Your answer
What is the best email address to reach you?
Your answer
Which LEA is the District of Special Education Accountability (DSEA) for this student?
*
Choose
Alpine
Barona
Cajon Valley
Dehesa
Grossmont
Jamul-Dulzura
La Mesa-Spring Valley
Lakeside
Lemon Grove
Mountain Empire
Santee
School of Attendance
*
Your answer
What is the SSID for this student? If you don't have it, you can leave this blank.
Your answer
Is this the first request for ADR services through East County SELPA for this student?
*
Yes
No
Other:
What concerns do you have that prompted a request for ADR support through the East County SELPA?
Lack of educational progress
Services not delivered consistent with IEP
Quality of virtual services
Poor communication
Other:
If this is not your first request for ADR services, what steps have taken place to come to an agreement as a team?
IEP Meeting
Meeting with school administrator
Meeting with District level administrator or support person
Meeting/ Collaboration with Exceptional Family Resource Center
Other:
Please share your concerns in more detail
*
Your answer
What other steps have you and the team taken to resolve these concerns and/ or disagreements?
Your answer
What would be your desired outcome?
Your answer
Submit
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