Online Intake Form for Special Education Case

Please fill out this form ONLY if you have a Special Education Case. PFCR does not handle school suspension matters.

* Indicates required fields
* Child’s name:
* Parent/Guardian’s name:
* Address:
Apt.:
* City:
* State:
* Zip Code:
* Home Phone:
Work Phone:
Cell Phone:
Email (if you have one):
* Child’s birthday:
* Total family income (yearly): (You will be required to provide documentation of yearly income.)
* Number of people in family:
* Grade:
* School:
Region/District:
*Child's disability or Classification in IEP:
Date of last IEP:
Check if non-English Speaking:	Yes, I'm a non-English Speaking
Language?
Legal problem presented:
Relief you are seeking:
Security Code:(case sensitive) Entering this code ensures requests are valid, not automated spam submissions.