CLIENT'S ON-BOARDING FORM
Welcome to SNACS, LLC!This document serves as the official record for your child's case with SNACS, LLC. It may take approximately 15 to 20 minutes to complete, depending on the complexity of your concerns or the information related to your child's educational records. Please ensure that this document is filled out prior to your client intake and onboarding meeting.Rest assured that your privacy is our priority. The information you provide will only be accessible to you and the SNACS, LLC team. Upon completion, you will receive a copy of this document for your records.We appreciate your trust in SNACS, LLC and look forward to supporting your family. Please note that if SNAC’s services are not retained, this form will be deactivated within 30 days.
Legal Guardian's Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
By signing this form, you consent to sharing your child's information with SNACS. Rest assured, our team highly values your privacy and is committed to protecting your family's and your child's data. If SNACS services are not retained, all provided documents and data will be securely deleted within 30 days.
SPECIAL NEEDS ADVOCACY AND COACHING SOLUTIONS, LLC CLIENT INTAKE FILE
Please write "N/A" if a question is not applicable. We value your time and appreciate your effort in completing this form. Your thorough responses are crucial for our team to gain a comprehensive understanding of your child's IEP and its legal considerations. Thank you for your cooperation.
Legal Guardian's Name
Relationship to Child
Employment Status
Who is/are the legal guardian/s of this child/student?
Legal Custody Status of parents/guardians if divorced or separated.
Who has legal rights to make educational decisions for this child/student?
Historically, how are educational decisions made for this child, Jointly or one parent/guardian?
Are there disagreements on how the child’s education should be implemented? If yes, what are these?
Back
Next
Student's Information
Name
First Name
Last Name
Nickname
Age
School Name
Grade level
School Address
School District
Special Education Director at District Level:
SpEd Administrator at School:
Back
Next
About your child's IEP/504/Accommodations:
Does your child have an IEP/504 Plan?
If there are other accommodations please state:
What is your child's most recent diagnosis?
If so, under what eligibility category is the child classified on the IEP?
Autism
Emotional Disturbance
Multiple Disabilities
Speech or Language Impaired
Other Health Impairment
Deaf-Blindness
Hearing Impairment
Orthopedic Impairment
Traumatic Brain Injury
ADD/ADHD
Developmental Delay (Ages 3-5)
Intellectual Disability
Specific Learning Disability
Visual Impairment
Other Health Impairments
To Be Determined
Do you Believe that your child's current diagnosis covers your child’s disability?
Yes
No
If No, please share your own observations regarding your child’s current status:
Does your child have multiple diagnoses?
Yes
No
If Yes, please elaborate here:
Is your child on any medications?
Yes
No
If Yes, please elaborate here:
Does your child have any health or medical concerns?
Yes
No
If Yes, please elaborate here:
Is your child experiencing any chronic medical conditions?
Yes
No
If Yes, please elaborate here (if possible, please include the name of the specialists, a contact number and location):
Is your child undergoing or have undergone any psychological or psychiatric conditions?
Yes
No
If Yes, please elaborate here (if possible, please include the name of the specialists, a contact number and location):
Has your child ever been hospitalized for a long period of time? (1 week or more)
Yes
No
If Yes, please elaborate here (if possible, please include the name of the hospital, duration, and reason for hospitalization):
Back
Next
STUDENT’S ACADEMIC RECORD
Have you attended your child’s IEP meeting before?
Yes
No
When was your child's most recent IEP?
If Yes, please elaborate here (you may share how many times and your child’s recent IEP’s major goal):
Have you attended your child’s 504 meeting before?
Yes
No
When was your child's most recent 504 plan meeting?
If Yes, please elaborate here (you may share the accommodation requested or provided):
What do you think your child’s level is in Reading?
Below grade level
On grade level
Above grade level
What do you think your child’s level is in Writing?
Below grade level
On grade level
Above grade level
What do you think your child’s level is in Math?
Below grade level
On grade level
Above grade level
What do you think your child’s level is in Sciences/Reasoning?
Below grade level
On grade level
Above grade level
Has your child experienced any of the following assessments? (Please put a check after the assessment)
Developmental Assessments
Screening Tests
Intelligence Quotient or IQ test
Academic Achievement Test
Adaptive Behavior Scales
Behavior Rating Scales
Curriculum Based Assessment
End-of-grade Alternate Assessment
Back
Next
Other Records
Have you or another party ever requested a due process hearing on behalf of your child?
Yes
No
If yes, please provide the necessary information:
Date of Request
Case Number
Petitioner:
Respondent:
Other Parties in Action:
Were you represented by an attorney?
Yes
No
Reason/s for Due Process Hearing:
Disposition or Outcome of Due Process Hearing:
Was an appeal filed by either Party?Were you represented by an attorney?
Yes
No
If yes, please provide information, however, we encourage you to complete the authorization to release form of SNACS before proceeding with sending this information. You may send it to us via email or via P.O Box.Do you have a copy of any type of settlement agreement? If yes, please provide information, however, we encourage you to complete the authorization to release form of SNACS before proceeding with sending this information. You may send it to us via email or via P.O Box. Has it been implemented by the Parties?
Has it been implemented by the Parties?
Is there currently a hearing pending before any administrative agency?
Yes
No
If yes, please provide the necessary information:
Date of Request
Case Number
Petitioner:
Respondent:
Other Parties in Action:
Basis for Due Process Hearing:
Scheduled Mediation date:
Scheduled Hearing date/s:
Back
Next
Thank you for completing this questionnaire:
We appreciate your time and effort, please complete the last part of this form:
I understand that this authorization will remain in effect one year from the date it is signed or until revoked by me, in writing, with delivery to the agency identified above with a courtesy written notification to Mr. Demian Garcia-Monroy a Special Needs Advocacy and Coaching Solutions (SNACS). My child's or my information will be protected and only Demian Monroy and its employees and contractors will have access; and may be released only for consultation or advocacy matters. Further possible reason(s) for release needs of Demian Garcia-Monroy to notify me and ask me for permission. Any additional advisors, attorneys, advocates shall be given information with identifiable information redacted
This file is completed by:
*
First Name
Last Name
Relationship to child:
I certify that I am (student’s name) parent/custodian/guardian.
Other person/s involved in helping to complete this questionnaire.
Please write NA if not applicable.
Signature of Parent/Guardian or Direct Client
*
Full Name
*
Please write NA if not applicable.
Date
-
Month
-
Day
Year
Date
What date and time work best for you? (REMINDER THIS FORM IS FOR FREE ONLINE CONSULTATION)
*
Would you like to receive free SNACS newsletters and stay informed about the latest SNACS news & Promotions, state wide and national advocacy updates, news, and important issues?
*
✅ Yes, keep me informed!
👎 No, maybe later.
Thank you again for completing this form! You will receive a copy of your completed form and please wait for our email or call!
SNACS CONTACT DETAILS: Phone: 714-881-9860 | 714-881-1416 - Email Address: snacs.ceo@gmail.com | snacs.co@gmail.com - P.O Box: P.O Box 1372 Garden Grove, CA · 92842
Continue
Continue
Should be Empty: