LYS Intake Form First Name(Required) Last Name(Required) Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneZip In which state are you looking for school options?(Required)In which state are you looking for school options?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWhat school options are you inquiring about?(Required) Preschool Microschools District Charter Private ESA STO IEP Evaluation Other How would you prefer to be contacted?(Required)How would you prefer to be contacted?Phone CallTextEmailTell us about your child.Child's Full Name Child's Age Child's Grade What is the name of the school where your child attends? What district is the school in? Medical diagnosis? If so, what? Are parents in agreement re: the child’s academic needs/struggles/suspected or diagnosed disabilities? (Please be as open as you feel comfortable on your spouse’s feelings/position/role in this process with your child)Does your child have an IEP?Does your child have an IEP?YesNoWhat are the disabilities listed? What evaluations were conducted? What was the last date of an IEP meeting? Have you requested any evaluations? Is this in writing, and has it been acknowledged by the school? If so, what is the date of your request? What evaluations have been requested/are in the process of being done? What are your Concerns?School Concerns Social Concerns Home Concerns Have you expressed these concerns to the school in a formal meeting or in written communication? What would you consider a successful outcome for your child?What are you hoping an advocate can accomplish for your family/child? Δ
