About You

First Name of Primary Contact:
Last Name of Primary Contact:
Relationship to Child/Young Adult:
Primary Contact Email:
Parent/Guardian First Name:
Parent/Guardian Last Name:
Email Address:
Best number to reach you:
Cell Phone:
Best time to reach you:
Time Zone:
Street Address:
City:
State:
Zip Code:

About the Student

Student First Name:
Student Last Name:
Student Age:
Street Address:
City:
State:
Zip Code:
Current Grade/Level:
Name of School:
School District:
Type of School:
Check the boxes for accommodations your student is currently receiving:
Classroom Setting:
Present Concerns:
Slow/No Progress
Curriculum Too Difficult
Poor Test Performance
School Refusal/Anxiety
Behavior (in school)
Behavior (at home)
Not Adequate Support at School
Current IEP Not Implemented
Placement Change Needed
Qualifying for Services
Need Help Modifying IEP
Mediation/Due Process Support
Transition to Adult Services
Private/Alternative School Search
SSI Application
Other Concerns
if other:
Related Services
Physical Therapy
Occupational Therapy
Speech Therapy
Resource Room
Pull-Out Therapy
Counseling
Nursing
Describe Concerns:
Medical (Check all that apply)
22q11.2 Standard Deletion
22q11.2 Partial Deletion
22q11.2 Duplication
Heart Defect
Immune Compromised
Feeding Issues
Speech/Language Delay
Low Muscle Tone
Hearing Impairment
Visual Impairment
Other Please explain:
Behavior/Social/Learning Challenges (Check all that apply)
ADHD
Autism
Depression
Writing Deficits
Difficulty with Math
Poor Reading Skills
Behavioral Challenges(oppositional)
Low Cognitive Ability
Psychosis
Withdrawn
Social Skills Deficits
Other
Annual Household Income:
Please upload any or all of the following documents naming each file as the name of the student and save :IEP (most recent signed)IEP (recent draft/amendment)Progress ReportReport Card (most recent)Past Report CardEvaluation(s) - school-basedEvaluation(s) - independentOther Reports - medical, therapist or other available report(s)
Document Upload #1:
Document Upload #2:
Document Upload #3:
Files must be less than 2 MB. Allowed file types: txt doc docx pdf xls xlsx jpg png gif. For larger files or files with different type, please scan and emailto us directly at: info@22qfamilyfoundation.org

Terms and Conditions

The 22q Family Foundation is providing this program free of charge as a service to the 22q community and to educational professionals. There is no warranty that program suggestions or placements will result in any specific outcome. Furthermore, the information provided through this program is not a substitute for legal advice regarding the IDEA law. Parents seeking legal advice are advised to consult an attorney that specializes in special education law. By checking below you agree to hold harmless the 22q Family Foundation and Cutler-Landsman Consulting for any outcomes or perceived damages resulting from these services.
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