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SPECIAL EDUCATION ADVOCACY SERVICES, LLC

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Inquiry for Potential Clients

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Parent/Guardian Name *

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Parent/Guardian Name *

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Address *

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Phone Number *

Email *

Student's Name *

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Last

Date of Birth (MM/DD/YYYY) *

Current grade level *

Previously retained *

If Yes, what grade level *

Current school your child attends *

Current teacher name *

Medical diagnoisis *

School (IEP or 504 plan) eligibility *

How did you hear about Ysela Heim and/or Special Education Advocacy Services, LLC *

Have you previously reached out or communicated with anyone from our office? *

If yes, who have you communicated with? *

Have you ever worked with an Educational Advocate or Attorney? *

Is your child currently receiving any of the following? *

Tutoring ABA Therapy Speech and/or Language Therapy Occupational Therapy Physical Therapy Social Skills Classes Vision Therapy Neuro/Cognitive Feedback Feeding Therapy Other None of the above

Concerns that you would like assistance with *

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General Questions or Comments

Should you have any questions or comments, feel free to let us know.
We THANK YOU for visiting our site.

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EMAIL ADDRESS:
contact@yselaheim.com
yselaheim@gmail.com

FAX NUMBER:
1-888-373-0014

MAILING ADDRESS:
18459 Pines Blvd, #413
Pembroke Pines, FL 33029