Special Education/Early Intervention 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.

Parent/Guardian Name
(Required)
Email
Phone
(R)
Address


(R)
Student Name
(R)
Describe the Problem:      (R)
School District:
School/School Address
Classification
Placement
Services
Any proposed solutions?
Other Party Email
Other Party Phone


Note: Please do not include any URLs in form.