The information entered into this form will help us prepare for the free consultation. Make sure that you hit the submit button AND schedule a time to have the consultation. We look forward to speaking with you.

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? *

Yes
No
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Your Significant Other's/Participant's Relationship to Student *

Father

Mother

Grandmother

Grandfather

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

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. *

Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
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Name of the school your child is attending *

Name of the School District *

Not in Colorado

Adams 12

Aurora

Boulder

Cherry Creek

Douglas

DPS

Jeffco

Littleton

Summit

Thompson

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

My child needs help - Not sure what to do
Initial 504
Initial IEP
Annual 504 Update
Annual IEP Update
IEP Re-evaluation
Initial ALP
Annual ALP Update
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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. If your child is on a 504 or IEP, please attach the document. If your child has had an evaluation done either by the school/private provider in the last 3 years, please attach the evaluation report.

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

Yes
No
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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!

Other