Intake Form

Special Education Intake

This form will help you describe the disagreement you have so you can request mediation. Once you have completed this form, you should mail or fax it to the Committee on Special Education (CSE) chairperson in the child’s district and to the Mediation Center listed below in the box. If you are a parent or guardian, it is also helpful to bring a copy of this request to your child’s school principal.

* Required

Your Name*

Required

Email

Phone*

Required

Address*

Required

Student Name*

Required

Describe the Problem:*

Required

Student Date of Birth

Any proposed solutions?

Other Party Email

Other Party Phone

Role

Parent Date of Birth*

Required

School District*

Required

School and School Address*

Required

Notes: Please do not include any URLs in the form. You might have to click "submit" twice.