Skip to content
(870) 918-3431
|
Contact Us
Search for:
About
Expertise
Benefits
News & Events
Payment
Resources
Search for:
About
Expertise
Benefits
News & Events
Payment
Resources
About
Expertise
Benefits
News & Events
Payment
Resources
Contact
Contact
Think Admin
2021-06-03T19:22:21+00:00
Please fill out form below to help us better understand your needs. A representative will get back with you as quickly as possible.
Please enable JavaScript in your browser to complete this form.
Child's Full Name:
*
Date of Birth:
Child’s current school, if enrolled:
Assigned grade level:
Is there a current IEP?
Yes
No
Date begun:
Reason(s) for IEP, or specific learning disability:
When did the last bad thing happen?
Brief description of current problem:
Date of next scheduled meeting with school personnel:
Parent/Guardian Full Name:
*
Parent/Guardian Mailing Address
Phone Number:
*
Email:
*
What is your preferred way for us to contact you? (You may select more than one.)
Phone Call
Email
Text Message
No Preference, Any is fine
Do you have legal authority to make educational and medical decisions?
Yes
No
Other Parent/Guardian Full Name:
Other Parent/Guardian Mailing Address - If seperate address
Other Parent/Guardian Phone Number:
Other Parent/Guardian Email:
Does other Parent/Guardian have legal authority to make educational and medical decisions?
Yes
No
Have you ever used advocacy or legal services for this child?
Yes
No
If Yes, Please Describe:
What would you like your advocate to do for you and your child?
When can we schedule your appointment? (Best Day/Time)
Preferred Payment Method for Services
Credit or Debit Card
Check
Do you prefer a monthly billing plan?
Yes
No
(You will not be billed for services until we agree on what services will be offered.)
Submit
Go to Top
