Date__________ Long Island Early Childhood Direction Center Intake Form Parents/Legal Guardian Information Names:(Mother)_____________________(Father)__________________________ Address:___________________________________________________________ City/State/Zip:______________________________________________________ What language(s) are spoken at home? English___Spanish____Other___________ Do you need an interpreter? Yes____No____ Phone: (home)_______________________Can we leave a message? Yes___No____ (cell)______________________ (work)____________________________ E-mail:__________________________ May we add you to our e-mail list? Yes No Child(ren) Information 1. Name:____________________________D.O.B________________________ Address (if different)____________________Gender:_____________________ School District:___________________________ Grade_________Age________ Diagnosis/Disability_______________________Year_____________________ 2. Name:____________________________D.O.B________________________ Address (if different)____________________Gender:_____________________ School:___________________________ Grade_____________Age___________ Diagnosis/Disability_______________________Year_____________________ How may we help you? Please check the topic(s) that applies to you. (1)___CPSE and CSE processes 9)____ Legal and Advocacy (2)___Least Restrictive Environment 10)____Home School Collaboration (3)___Parent’s Rights 11)____Transition ____a. Early Intervention (4)___Day care and childcare services ____b. CPSE to CSE (5)___Family Support and Respite Services (6)___Social Services (7)___Vocational and Job Training Programs (8)___Evaluation and Diagnostic Services (12)Other_____________________________________________________________ How did you hear about us?_____________________________________________ Question/Concern: LIECDC staff member______________________________________ Action taken/Information provided/# of contacts:
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