* Required Information
Parent/Guardian Full Name(s):
*
Email Address:
*
Phone Number:
*
Home Address:
*
Preferred Method of Communication:
*
Phone
Email
Text
Student’s Full Name:
*
Preferred Name/Nickname:
*
Date of Birth:
Current Grade Level:
*
Anticipated Start Date (e.g., August 2025):
Diagnosis (if applicable):
Current or Previous Schools/Programs:
*
Does your child have an IEP or 504 Plan?
*
Yes
No
In Progress
Please upload/email IEP or recent evaluations (optional):
Choose a file
Does your child currently receive any services?
*
ABA
Speech Therapy
Occupational Therapy
Physical Therapy
Other:
Communication style (verbal, AAC, signs, gestures, etc.):
Sensory needs or preferences:
*
What are your academic goals for your child?
What are your social/emotional or behavioral goals?
What kind of learning environment do you feel your child thrives in?
Anything else you’d like us to know?