The information entered into this form will enable us to contact you and support you appropriately.

Your Information

Primary Contact First Name *

Primary Contact Last Name *

Primary Contact Mobile Phone Number *

Primary Contact Email *

How did you hear about Learning Differences World? Please be specific and, if applicable, provide name of person. *

Significant Other/Participant Information

Do you have a significant other or someone who will also participate in our work together? *

Significant Other/Participant First Name *

Significant Other/Participant Last Name *

Significant Other/Participant Mobile Phone Number *

Significant Other/Participant Email *

Please include my Significant Other/Participant on all emails/texts.

Yes

Please include my Significant Other/Participant as a contract signer.

Yes

Child Information

First Name of child/student we will be advocating for. *

Last Name of child/student we will be advocating for. *

Birthdate of child/student we will be advocating for. *

Indicate the grade your child is entering. *

Name of the school you child is attending *

Select the item that best reflects where you are in the special education process. *

Please describe your major concerns about your child's education

Let us know any issues you believe need to be addressed earlier than anticipated. For an annual IEP update, we would usually contact the school at least 6 weeks before the due date. For a re-evaluation/triennial, we would contact the school at least 10 weeks before the due date.

Please provide any other comments you feel that LDW needs to know about your child or your interactions with the school/district.

If your child has an official diagnosis from an MD, Psychologist, or Speech Pathologist, please explain.

Please attach files/emails that will help us prepare for our meeting.

Are you planning on a 3rd party paying for LDW services?

Please provide the name of the person/organization that will be paying for at least some your services. *

Developmental Pathways

Rocky Mountain Human Services

DDRC

Imagine!

Additional Child?

Do you have another child you might like services for?

Yes