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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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Last

Address *

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City

State

Zip Code

Country

Phone Number *

Email *

Student's Name *

First

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 and comments

Should you have any questions or comments, feel free to let us know. This section is not for potential clients but for professionals looking to collaborate or comment.
We THANK YOU for visiting our site.

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Email *

Phone # *

Question or comment *

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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