Parent Input Form
Please fill out the following information accurately.
Parent's Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child’s age and current grade level:
*
Does your child have a diagnosed learning difference or disability? (Examples: dyslexia, ADHD, autism, etc.) If yes, please share any relevant details. If there’s no formal diagnosis, briefly describe the challenges your child is experiencing.
*
What concerns do you have about your child’s IEP, 504 plan, or academic progress? (Examples: missing services, unclear goals, lack of growth, or insufficient support.)
*
Upon completion of this form, please email your child's IEP to: agriffith@empowereducationservices.com and put FREE IEP REVIEW + your child's last name in the subject line. We will review your IEP and send you a summary of our findings within 5 business days. The information you provide will be used solely for the purpose of conducting a confidential IEP review and communicating my findings with you. All details you share will remain private and will never be shared with anyone else without your explicit permission. You are welcome to redact any portions of your child’s IEP that you are not comfortable sharing with Empower Education Services, LLC.
I understand that my information will not be shared and that all communication between Empower Education Services, LLC and me is strictly confidential.
Submit
Should be Empty: