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Parent Full Name

Parent Date of birth *

Email *

Cell Phone *

Address *

City *

State *

Zip Code *

Household Status *

How many members reside in your household? *

Military *

Education Level *

Employment *

What is your annual household income? *

How Did You Hear About Brighton Center *

What is your confidence or experience level with the special education process, using the numbers 0-10 (0 being the least confident - 10 very experienced and/or confident) *

Have you ever received Brighton Center Advocacy / Consultation services? *

Yes

We would love to know more about these Brighton Services: *

Brighton Preschool

Brighton Early Childhood Intervention for 0-2 Year Olds

Brighton Pediatric Therapy Clinic for 3 - 5 Year Olds

Special Education Support Services

Parent Workshops

None

Your Child's Information

Child First Name *

Child Last Name *

Child Date of Birth *

Child's Gender *

Male

Female

Language Spoken at Home *

Does Your Child Currently Receive Early Childhood Intervention Services from Brighton Center *

Yes

Current Full Name of School (no abbreviations) *

Grade *

School District *

Please explain concerns you are having about your child *

Child Primary Disability *

Child Secondary Disability

Child Additional Disability

What is your desired outcome from our services? *

Documentation

Most Current Individualized Education Program (IEP)

Any Private Evaluation related to your child's disability (ies)

PDFs Only, Max 15 Files

Behavior referral slips

PDFs Only, Max 15 Files

Behavioral Data from school (ABC data)

PDFs Only, Max 15 Files

Other Documentation that gives insight into your case

PDFs Only, Max 15 Files

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