Special Education

Initial Intake Form – Special Education

Please complete all the boxes on this form and then click submit. Please note you will be requested mail or fax the records at the end of this document so we can begin the intake process.

Note: This form is submitted via email. If you do not have a POP email account (i.e. you use a web-based email such as Yahoo or Hotmail) then you may get an error message when submitting the form. If you get an error, please print the form and mail it to our office at: Disability Law Center of Alaska, 3330 Arctic Boulevard, Suite 103, Anchorage, AK 99503

Client Information

Today's Date:
Referred by:
Child’s Name:
Age:
Grade:
Child’s Disability:
Current School:
Date of last IEP/504:
Is your child in school presently?	YES NO
Explain:

Parent’s Contact Information:

Parent’s Name:
Parent’s Address:
Telephone Number(s):
Home:
Work:
Fax:
Email:

WHAT IS THE PROBLEM? (parents view)

Medical History:

Initial diagnosis, date and treating doctor/psychologist:

Most recent diagnosis, date and treating doctor/psychologist:

Educational Programming - Present:

Present school and District:
Date of last IEP parent agreed with:
Latest Evaluation Date:
Program:
Teacher/Contact:

List three positive aspects of the school district’s present program for your child:

List three items you don’t like about the school district’s present program for your child.

Educational History:

List all the schools your child has attended (include preschool), grades attended and whether your child was in special education programs during the years listed. (If you need more room, write on the back of this page.)

List all of the teachers who have worked with your child whom you consider to be great teachers and why.

List all of the teachers who have worked with your child whom you think could have done a better job and explain why.

Related Information:

Has your child ever been placed in a facility out of the state of Alaska? If so, explain.

Have you received any written information about your special education rights? (Note: This information can be found on DLC’s website).

Has your child been involved in the juvenile justice system? If so, explain.

Has anyone ever referred you to Office of Children’s Services? If so, explain.

Does your child receive Social Security, Medical Assistance or any other government benefits? If so, explain.

Have you ever hired an attorney for any purpose?

Have you ever had an advocate for your child?

Have you talked to the school district about your concerns?

Have you requested or attended an IEP meeting to discuss your concerns or written the school district about your concerns?

Have you participated in resolution or mediation with the district about your concerns?

Documents

For us to be able to begin the intake process we need you to fax or mail the following information: us the following documents. We will contact you when we receive and review this intake sheet and your student's records. Thank you!

Child’s most recent IEP or 504 plan.
Child’s most recent evaluation.
Any relevant correspondence and information.

Telephone	Address
Phone: 907-565-1002 Phone/TTY Fax: 907-565-1000 Toll Free: 1-800-478-1234 Phone/TTY (In State Only)	Disability Law Center of Alaska Mail: 3330 Arctic Boulevard, Suite 103 Anchorage, AK 99503 E-mail: akpa@dlcak.org

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Special Education