| Data Name |
Data Type |
Options |
| Parent/caregiver calling about a child/young adult |  Text Box | |
| First name | Text Box | |
| Last name | Text Box | |
| Password | Text Box | |
| Email | Text Box | |
| Phone (mobile) | Text Box | |
| City | Text Box | |
| State | Text Box | |
| Zipcode | Text Box | |
| Gender | Text Box | |
| Parent/caregiver calling about a child/young adult |  option |
* = a required field
Need assistance with this form?
Are you a... |
| Professional calling about a child/young adult | option | Parent/caregiver calling about a child/young adult |
| Professional calling about general information | option | Professional calling about a child/young adult |
| Borough |  dropdown | Please select... |
| Primary Language | dropdown | Please select... |
| State | dropdown | Please select... |
| Male | option |
Gender |
| Female | option | Male |
| Individualized Family Service Plan (IFSP) |  checklist |
Does your child have |
| Individualized Education Program (IEP) | checklist | Individualized Family Service Plan (IFSP) |
| 504 Plan | checklist | Individualized Education Program (IEP) |
| None | checklist | 504 Plan |
| I Don't Know | checklist | None |
| Individualized Education Program (IEP) Classification | dropdown | Please select... |
| Disability | dropdown | Please select... |
| Relationship to child | dropdown | Please select... |
| Public education system | option |
I am concerned about |
| Non-school systems or concerns | option | Public education system |
| Information and/or referral | option | Non-school systems or concerns |
| Other | option | Information and/or referral |
| 504 | checklist | Other
My Specific Areas of Concern are
|
| Assistive Technology | checklist | 504
|
| Behavior Supports/ Issues | checklist | Assistive Technology
|
| Clarification of Rights | checklist | Behavior Supports/ Issues
|
| Diploma Options | checklist | Clarification of Rights
|
| Early Intervention | checklist | Diploma Options
|
| Emergency Svcs./Crisis Intervention | checklist | Early Intervention
|
| Harassment/Bullying | checklist | Emergency Svcs./Crisis Intervention
|
| Individualized Education Program (IEP) Compliance | checklist | Harassment/Bullying
|
| Meeting Prep: Individualized Education Program (IEP) | checklist | Individualized Education Program (IEP) Compliance
|
| Meeting Prep: Impartial Hearing | checklist | Meeting Prep: Individualized Education Program (IEP)
|
| Meeting Prep: Mediation | checklist | Meeting Prep: Impartial Hearing
|
| Meeting Prep: Resolution Session | checklist | Meeting Prep: Mediation
|
| Other | checklist | Meeting Prep: Resolution Session
|
| Post Secondary Education/ College | checklist | Other
|
| Preschool | checklist | Post Secondary Education/ College
|
| Process/Guidance (Education) | checklist | Preschool
|
| Safety Transfer | checklist | Process/Guidance (Education)
|
| School Placement: High School | checklist | Safety Transfer
|
| School Placement: Kindergarten | checklist | School Placement: High School
|
| School Placement: Middle School | checklist | School Placement: Kindergarten
|
| School Placement (request to change) | checklist | School Placement: Middle School
|
| Transportation | checklist | School Placement (request to change)
|
| Turning 5 | checklist | Transportation
|
| Accessible Housing/ Adaptation | checklist | Turning 5
My Specific Areas of Concern are
|
| Conservatorship | checklist | Accessible Housing/ Adaptation
|
| Equipment | checklist | Conservatorship
|
| Guardianship | checklist | Equipment
|
| Navigating Services: Medicaid Waiver | checklist | Guardianship
|
| Navigating Systems: Housing | checklist | Navigating Services: Medicaid Waiver
|
| Navigating Systems: MSC | checklist | Navigating Systems: Housing
|
| Navigating Systems: OPWDD | checklist | Navigating Systems: MSC
|
| Other | checklist | Navigating Systems: OPWDD
|
| Public Benefits (food stamps/rent asst) | checklist | Other
|
| Residential Programs (After 21y.o) | checklist | Public Benefits (food stamps/rent asst)
|
| Respite | checklist | Residential Programs (After 21y.o)
|
| SSI/SSDI | checklist | Respite
|
| Vocational/Employment Training | checklist | SSI/SSDI
|
| Camp/Day | checklist | Vocational/Employment Training
My Specific Areas of Concern are
|
| Camp/Sleep Away | checklist | Camp/Day
|
| Child Care | checklist | Camp/Sleep Away
|
| Evaluation | checklist | Child Care
|
| Financial Assistance | checklist | Evaluation
|
| Health/Medical | checklist | Financial Assistance
|
| Legal Services | checklist | Health/Medical
|
| Mental Health Svcs. | checklist | Legal Services
|
| Other | checklist | Mental Health Svcs.
|
| Parenting Skills Training | checklist | Other
|
| Recreation/After School | checklist | Parenting Skills Training
|
| Support Group | checklist | Recreation/After School
|
| Therapies (ABA OT PT SP/L etc) | checklist | Support Group
|
| Tutoring | checklist | Therapies (ABA OT PT SP/L etc)
|
| Referral from school | checklist | Tutoring
How did you find out about us? |
| Referral from non-school professional | checklist | Referral from school |
| DOE form/letter | checklist | Referral from non-school professional |
| Have received direct assistance from INCLUDEnyc/RCSN before | checklist | DOE form/letter |
| Attended INCLUDEnyc event: workshop, fair, etc. | checklist | Have received direct assistance from INCLUDEnyc/RCSN before |
| Internet search | checklist | Attended INCLUDEnyc event: workshop, fair, etc. |
| Referred by other organization | checklist | Internet search |
| Word of mouth: parent | checklist | Referred by other organization |
| Word of mouth: other | checklist | Word of mouth: parent |
| None of the above | checklist | Word of mouth: other |
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