Special Ed Advocacy Center Intake Form (Client
Request for Services Form)
Return form by mail 1935 Plum Grove Road PMB
274, Palatine, IL 60067
or fax (847) 397-7011.
DATE:
FILE NUMBER (assigned by office mgr)
FIRST NAME :
LAST NAME:
ADDRESS :
HOME TELEPHONE:
OTHER PHONE :
EMAIL:
FAX:
CHILD'S NAME :
CHILD'S DATE OF BIRTH:
GRADE LEVEL:
ETHNICITY:
RACE:
SPECIAL NEEDS:
TOTAL FAMILY INCOME :
NUMBER OF INCOME EARNERS :
NUMBER OF DEPENDENTS :
INCOME SOURCE:
PUBLIC BENEFIT $______________
SALARY $_____________________
CHILD SUPPORT $______________
SS/SSI $________________________
OTHER $_______________________
SOURCE ______________________
PLACE OF EMPLOYMENT :
POSITION/TITLE:
PLACE OF EMPLOYMENT:
POSITION/TITLE :
HOW DID YOU HEAR ABOUT SEAC? :
REASON FOR NEEDING ASSISTANCE FROM SEAC (attach additional
sheet(s) if necessary):
____________________________________________________________________________________________________________________
FORM OF REPRESENTATION_____ Advice Only; _____ Information Only;
_____ Brief Service: ______________________________; _____ Attend
IEP; ______ Mediation; _____ Administrative Hearing; _____ Litigation.
NOTE: INFORMATION IS GATHERED FOR STATISICAL PUPOSES ONLY.