Providing Resources For Parents and Educators
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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.
Requested By:Parent/GuardianLEA (school district; charter; or IU)Infant/Toddler / Early Intervention
Name of Person Completing this Form:
Email of Person Completing this Form:
Relationship to Student:MotherFatherGuardianN/A
Phone:ex: 000-000-0000 or 000-000-0000x000
Please check the type of service requested:IEP FacilitationMediationGIEP FacilitationIFSP Facilitation (Early Intervention)
Date of Birth: MM/DD/YYYY
Exceptionality(ies):AutismDeaf-BlindnessDevelopmental DelayEmotional DisturbanceGiftedHearing Impairment (including Deafness)Intellectual DisabilityMultiple DisabilitiesNot eligibleOrthopedic ImpairmentOther Health ImpairmentProtected HandicappedSpecific Learning DisabilitySpeech or Language ImpairmentThought to have disabilitiesThought to be giftedTraumatic Brain InjuryVisual Impairment (including Blindness)
Name of School/Program:
Address Street, Apt. No., PO Box, etc. and City / State / ZIP:
Home Phone:ex: 000-000-0000 or 000-000-0000x000
Work Phone:ex: 000-000-0000 or 000-000-0000x000
Cell Phone:ex: 000-000-0000 or 000-000-0000x000
Second Parent or Parent not residing with the Student:
Local Education Agency (LEA) Information
School District / Charter School / Agency Name:
Address Street, PO Box, Room, etc. and City / State / ZIP:
Please provide a brief description of the issue(s) in dispute, and any proposed solutions to the problem*:
Please complete this section if you are requesting any type of facilitation service.
An IEP/IFSP/GIEP meeting is currently scheduled for:date, time and location
Location of IEP meeting:
An IEP/IFSP/GIEP meeting has not yet been scheduled. Not scheduled
Has a due process hearing already been requested? YesNo
For all requests, if there is additional information you would like to provide, please enter it here:
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