If you have already scheduled your consultation, please fill out our intake form by clicking the button below. Click here to read more about what to expect during an initial consultation.

INTAKE FORM

Date of Consultation

YYYY

Child's Name

First Name

Last Name

Date of Birth

YYYY

NYC ID#

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone #

(###)

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Parent 1 Name

First Name

Last Name

Parent 1 E-mail

Parent 1 Work #

(###)

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Parent 1 Cell #

(###)

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Parent 2 Name

First Name

Last Name

Parent 2 E-mail

Parent 2 Work #

(###)

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Parent 2 Cell #

(###)

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Secondary Address (if applicable, please identify which parent's address this is)

Who referred you to us?

Child's Current School Placement

Current School District

Please list the names of all private evaluators, therapists, psychiatrists, and tutors that are currently working with your child

Present Problem

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By checking this box, you acknowledge that during the initial consultation, we will review your child's educational history and provide certain advice and recommendations in accordance with your educational plans and past actions. This consultation does not create an ongoing attorney-client relationship unless a separate agreement is entered into between you and our offices.