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Minor Child Intake Questionnaire
Please complete this questionnaire if you are contacting our office about a child under the age of 18.
Name of person completing form
First Name
Last Name
What is the child's name?
First Name
Last Name
What is your relationship to the child?
Please Select
Parent
Legal Guardian
Other
What is your email?
example@example.com
What is your mailing aaddress?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child live at the same address as you?
Yes
No
What is your phone number?
Please enter a valid phone number.
Format: (000) 000-0000.
What is the child's date of birth?
-
Month
-
Day
Year
Date
How did you hear about our office?
What is your preferred language?
Please Select
English
Spanish
Other
What grade is your child in?
Have you applied for Social Security (SSI) benefits for your child?
Yes
No
Other
If you have already filed, has your child's SSI claim been denied?
Yes
No
Other
If your child's case was denied within the past 65 days, please provide the date of the denial.
Please describe the nature of your child's disability/disabilities.
Does your child have an IEP or 504 plan?
Yes
No
I don't know
Is your child receiving medical treatment for their disability/disabilities?
Yes
No
Is there any other information you would like for us to know about the case at this time?
How would you prefer to be contacted?
Phone
Email
Other
Submit
Should be Empty: