Details About Your Case — Zatopa, Stephens & Kurzrock

Special Education Questionnaire

If you are the parent or guardian of a disabled student and are seeking legal representation for obtaining special education support from a local public school district, please fill out the Special Education Questionnaire link, complete the form, and send it to us. Someone from our office will get back to you shortly.

Special Education Questionnaire

General Information

Parent / Guardian Name

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Information

Student's Name

First Name

Last Name

Student's Age

Student's Special Education Category

Case Details

Date of Last IEP

MM

DD

YYYY

Next IEP Scheduled

MM

DD

YYYY

Date of Last Assessment (School or Private)

MM

DD

YYYY

Nature of Dispute

Please include specifics, e.g., School district refuses to find my child eligible for special education, My child needs a private school placement with the following components and the school has offered a program with…., My child needs 5 hours of speech therapy a week, the school offered 1 hour per week, etc.

Have you had any discussions with the school district about the dispute?

Yes

No

Have you filed for due process?

Yes

No

Corporate Questionnaire

If you are the representative of a corporation that contracts with a California public school district to provide special education, mental health or other services to special education students, and/or operate a Non-Public School (NPS) or Non-Public Agency (NSA), please hit the Corporate Questionnaire link, complete the form, and send it to us. Someone from our office will get back to you shortly.

Corporate Questionnaire

General Information

Name of Corporation

Name of Executive Director

First Name

Last Name

Nature of Operations

Your Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

General Information About Your Agency

Number of Children Served

Number of Children Served with IEPs

Number of Government Agencies Contracting with Agency

Student's Special Education Category

Nature of Presenting Problem

Government Agency (ies) involved, if any

Has any formal legal actions been taken against you by a government agency?

Yes

No

If Yes, what action?

Any specific dates pending?

Yes

No

If Yes, what dates?

Nature of Dispute or Presenting Problem

Please include specifics, e.g., Community Care Licensing has given repeated citations for runaways; the school district refuses to respond to our referrals for special education assessment; our rate for our group home or NPS is __% below our cost of services, etc.

Have you had any discussions with the government agency involved about the dispute?

Yes

No

If yes, where are the parties at this point?

Have you or any representative filed or sent any formal or informal response regarding the dispute or problem?

Yes

No