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:
* 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:
*Child's disability or Classification in IEP:
  Date of last IEP:
Check if non-English Speaking:  Yes, I'm a non-English Speaking
Legal problem presented:
Relief you are seeking:
Security Code:(case sensitive)

Entering this code ensures requests are valid, not automated spam submissions.

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