Solange Captan Legal, P.C.

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Intake Form

551-218-9397

Menu

Home
About
Services
FAQs
Attorney Profile
Contact
INTAKE FORM

INTAKE FORM

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INTAKE FORM

If you’re looking for guidance or would like to schedule an initial consultation about your child’s special education needs, we invite you to fill out the form below.

Sharing as much information as you feel comfortable with helps us understand your concerns.

If you call our office to book a consultation, we will kindly direct you to this form so we can gather the information we need to support you.

Please note that submitting this form does not create an attorney–client relationship.

We truly look forward to connecting with you and learning more about how we can help your child.

Personal information

Full Name

Relationship to Child

Phone Number

Email Address

Parent Information

Parents 1 Name

Relationship to Child

Parent 1 Phone Number

Parent 1 Email Address

Parent 1 Mailing Address

Parent 1 School District where you reside

Parents 2 Name

Relationship to Child

Parent 2 Phone Number

Parent 2 Email Address

Parent 2 Mailing Address (if different from Parent 1)

Parent 2 School District where you reside (if different from Parent 1)

Family Dynamics

Are parents divorced?

Yes No

If yes, do you have final educational decision making authority?

Yes No

Custody status (if relevant)

Both Parents Single Parent Guardian

Primary language spoken at home

Which School District does the child reside in

Child’s Information

Full Name

Date of Birth

Gender (optional)

School Name and District

Grade

Residency

Do you and your child currently reside in NJ or NY?

NJ NY Other

Please Specify

If relocating, when and where?

What is the name of your school district?

Urgency & Deadlines

Are there any upcoming IEP meetings, CST evaluations, or disciplinary hearings? Date(s):

Is your child currently receiving home instruction or out-of-placement services?

Yes No

Education & Services Background

Does your child have an IEP?

Yes No

If yes, date of most recent plan:

Does your child have an IESP?

Yes No

If yes, date of most recent plan:

Does your child have a 504 Plan?

Yes No

If yes, date of most recent plan

Date(s) of last school district evaluation

Type(s) of evaluation

Date(s) of last private evaluation (if any)

Type(s) of evaluation

Diagnosis(es):

Does your child receive

Speech Therapy OT PT Counseling Art Therapy Music Therapy Social Skills ABA Other

Please Specify

Areas of concern (check all that apply)

Academic Behavior Communication Emotional Discipline/suspension Services not provided Placement disagreement Other

Please Specify

Legal Issues / Reason for Contacting Us

(Briefly describe the issue or concern that brings you to our office)

Documents Available

Documents Available

Most recent IEP 504 Plan Evaluation Reports Report Cards Emails Disciplinary Records Progress Reports Other

Please Specify

Medical, Therapeutic & Educational Providers

Provider Name, Role/Specialty, Email, Phone

Provider Name, Role/Specialty, Email, Phone

Other

Do you have written reports?

Yes No Not Sure

Are your providers willing to communicate with our office (with permission)?

Yes No Not Sure

Procedural History & Advocacy

Have you previously hired an attorney or advocate for this child?

Yes No

If yes, who and when?

Have you attended mediation, due process hearings, or filed complaints?

Mediation Due Process OCR Complaint State Complaint None

Outcome:

Parent Concerns & Goals

What do you feel your child needs most right now?

What is your desired outcome from our involvement?

IEP Meeting Support Additional Services Placement Change Compensatory Services Dispute Resolution Other

Please Specify

Relief You Are Seeking (Please check all that apply):

Help with Public School Placement Private School Placement / Tuition Reimbursement Funding for a Home-Based Program (e.g., ABA, related services) IEP Advocacy / Meeting Support Compensatory Education or Related Services Mediation or State Complaint Due Process Hearing Other

Please Specify

Communication with School

How is communication with your school team?

Positive & collaborative Neutral Strained or adversarial

Do you have a case manager or primary school contact? Name/Role:

Disciplinary History

Has your child been suspended, expelled, or disciplined this school year?

Yes No

If yes, provide dates/reasons:

Academic Performance

Does your child meet grade-level standards?

Yes No

If no, please describe concerns:

Has the school provided progress reports or data?

Yes No

How Did You Hear About Us?

How Did You Hear About Us?

School Referral Another Attorney Social Media Website Word of Mouth Other

Please Specify

Schedule Your Consultation

Complete the form and our team will contact you to review your case and discuss next steps.

If you’re looking for guidance or would like to schedule an initial consultation about your child’s special education needs, we invite you to fill out the form below as well as complete the Intake Form on our website.

First Name

Last Name

Phone Number

Email Address

Message

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New York Office

254 S Main St #515,
New City, NY 10956

Monday-Friday-By Appointment Only

New Jersey Office

Bergen County, New Jersey

Monday-Friday Virtual Office – By Appointment Only

Contact Info

551-218-9397
Solange@scspecialedlaw.com

Legal Disclaimer: This website is for informational purposes only and does not constitute legal advice. Viewing this site or contacting the firm through this site does not create an attorney-client relationship. Past results do not guarantee future outcomes. Please do not send confidential information until an attorney-client relationship has been formally established.

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