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Educational Advocacy Intake Form
Thank you for completing this educational advocacy form to help me better assist your child.
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Your First Name
Parent or Legal Guardian's Name
Your answer
Your Last Name
Parent or Legal Guardian's Name
Your answer
Street Address
Your answer
Apt, Building
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email
Your answer
Phone Number
Your answer
Your Relationship to Student
Mother
Father
Guardian
Other:
Clear selection
Student's First Name
Your answer
Student's Last Name
Your answer
Students Date of Birth
MM
/
DD
/
YYYY
School ID
Your answer
Current Grade
If completing this form in the summer months, please indicate what is the grade child has just completed.
Choose
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Student's Current School
Your answer
School Classification
Elementary
K-8 Center
Middle School
High School
"Alternative" School includes juvenile justice facility
Clear selection
Type of School
Traditional Public School
Charter Public School
Private School
Clear selection
Student's School District
Please include name of school district, city, and state, if private school just include city and state.
Your answer
Has your child ever repeated a grade?
Yes
No
Clear selection
If your child has repeated a grade, please indicate which grade(s) he/she repeated.
Your answer
Has your student ever been evaluated for exceptional student education?
If no current diagnosis, please put NA for Not Applicable
Yes, to determine eligibility for special education
Yes, to determine eligibility for gifted education
No, but a request for evaluation has been made
No, but I am interested in discussing if an evaluation is needed for my student
Clear selection
When were the evaluations completed?
If no evaluations have been completed, please leave blank.
MM
/
DD
/
YYYY
Diagnosis(es)
If no current diagnosis, please put NA for Not Applicable
Your answer
Have you ever asked for an Independent Evaluation for your student?
If no current diagnosis, please put NA for Not Applicable
Yes
No
N/A
Clear selection
Type of Plan
IEP
504
RTI
None
Please indicate how your child's day different than that of non-disabled children in any of the following ways.
Curriculum
Length of school day
Length of School Year
Transportation
No, my child's day is not different that that of non-disabled children
Other:
Does your student have any behavior issues?
Yes
No
Clear selection
If your student has behavior issues, briefly explain.
Your answer
Has your student's school ever conducted a Functional Behavioral Assessment (FBA)?
Yes
No
Clear selection
Has your student ever been suspended from school?
Yes
No
Clear selection
Please share approximately how many TIMES in your student's educational career that they have been suspended from school?
Your answer
Please share approximately the average NUMBER OF DAYS your child was suspended in a single incident
Your answer
Approximately how many days is your child absent in a single school year?
This is absences for illness and travel. Do not include days student may have been suspended.
Your answer
Have you ever attended an IEP meeting?
Yes
No
Clear selection
Have you ever requested services for your student that were denied by the school?
Yes
No
Clear selection
If you have ever requested services for your student that were denied by the school please explain.
Your answer
Is your student currently on medication?
Yes
No
Clear selection
If your child is currently on medication, please state what medication they are currently taking.
If no current medication, please put NA for Not Applicable
Your answer
Has your student previously been on medication?
Yes
No
Clear selection
Number of adults living in the home.
Please indicate the relationship of the named individuals to the student. EXAMPLE: Juan (father) Julia (mother) James (uncle) John (sibling) Ana (sibling)
Choose
1
2
3
4
5
Number of children living in the home.
Please indicate the relationship of the named individuals to the student. EXAMPLE: Juan (father) Julia (mother) James (uncle) John (sibling) Ana (sibling)
Choose
1
2
3
4
5
6
7
more than 7
Language spoken by mother
Please indicate which is the primary language spoken. If proficient in more than language, check all that apply.
English
Spanish
Haitian Creole
N/A- mother not in home
Other:
Language spoken by father
Please indicate which is the primary language spoken. If proficient in more than language, check all that apply.
English
Spanish
Haitian Creole
N/A- father. not in home
Other:
Language spoken by student.
Please indicate which is the primary language spoken. If proficient in more than language, check all that apply.
English
Spanish
Haitian Creole
N/A- father. not in home
Other:
Is student in ESOL?
Please indicate if child is in the English to Speakers of Other Languages program.
Yes
No
Clear selection
Does your family have any history of disabilities, speech, or reading problems? If yes, please share who in the family and what is their history.
Your answer
Does your family have any history of mental health issues? If yes, please share who in the family and what is their history.
Your answer
Please provide a brief description of why you are seeking educational advocacy services for your child.
Your answer
List All Agencies, Service Providers, School, and other Resources that are involved with your child's education (including therapies, counseling, tutoring, and after-school providers, etc).
Your answer
How did you hear about Angel Pittman?
Your answer
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