IEP/IFSP Facilitation/Mediation Request Form

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Request Form for IEP/IFSP Facilitation & Mediation.

Fill out the following form online.
The form must be completed in its entirety with a value for all required fields. Partial forms cannot be saved and accessed at a later date.






ex: 000-000-0000 or 000-000-0000x000

Student Information




MM/DD/YYYY

Parent/Guardian Information

Parent/Guardian Name(s):




Street, Apt. No., PO Box, etc. and City / State / ZIP:

ex: 000-000-0000 or 000-000-0000x000

ex: 000-000-0000 or 000-000-0000x000

ex: 000-000-0000 or 000-000-0000x000

Second Parent or Parent not residing with the Student:




Street, Apt. No., PO Box, etc. and City / State / ZIP:

ex: 000-000-0000 or 000-000-0000x000

ex: 000-000-0000 or 000-000-0000x000

ex: 000-000-0000 or 000-000-0000x000

Local Education Agency (LEA) Information



Street, PO Box, Room, etc. and City / State / ZIP:



ex: 000-000-0000 or 000-000-0000x000

ex: 000-000-0000

Please complete this section if you are requesting any type of facilitation service.


date, time and location



  • Parents with questions about these services or other dispute resolution options may contact the Special Education ConsultLine at 800-879-2301 or 717-901-2146” .
  • Any birth-3 questions should be referred to OCDEL at 717-346-9320.
  • On occasion, an ODR staff person may ask to attend any of these meetings for purposes of evaluating the service. Parties will be notified ahead of time, and any questions will be addressed at that time.