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)
captcha

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

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