Intake Form

If you have already scheduled your consultation, please fill out our intake form by clicking the button below.

Date of Consultation (required)Child's Name

First Name

Last Name

Date of Birth (required)NYC ID#Child's Home AddressCountryAddress Line 1 (required)Address Line 2

City (required)

State (required)

Zip Code (required)

Home Phone #Parent 1 - First and Last NameParent 1 - EmailParent 1 - Work #Parent 1 - Cell #Parent 2 - First and Last NameParent 2 - EmailParent 2 - Work #Parent 2 - Cell #Marriage StatusSecondary Address (if applicable, please identify which parent's address this is)Who referred you to us?Child's Current School PlacementCurrent School DistrictPlease list the names of all private evaluators, therapists, psychiatrists, and tutors that are currently working with your childPresent ProblemBy 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.Agree

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.