Early Intervention Due Process Request Form

After completing this online form, you will receive a copy of the submitted information via email. The information contained in this email should be sent to the opposing party; parents would send it to the Lead Agency (LA), and LAs would send it to the parent. Fields with an asterisk (*) indicate a required field; all other fields are optional.

Early Intervention Due Process Request Form (English)

  • Basic Information

    If you require special accommodations to participate in the due process hearing, you must notify the LA (Lead Agency)
  • ex: 000-000-0000 or 000-000-0000x000

  • Child Information

  • MM slash DD slash YYYY
  • e.g., Early Intervention Provider
  • e.g., KinderCare

  • Parent(s) Residing with Child

  • e.g., 000-000-0000x000

  • Second Parent at Same Address:

    Parent(s) Residing with Child cont.
  • e.g., 000-000-0000x000
  • e.g., 000-000-0000 or 000-000-0000x000

  • Parent(s) Not Residing with Child

  • e.g., 000-000-0000x000
  • e.g., 000-000-0000 or 000-000-0000x000

  • I. LA Contact Person Information

    Lead Agency (LA) Information
  • ex: 000-000-0000 or 000-000-0000x000

  • II. County Administrator

    Lead Agency (LA) Information cont.
  • e.g., 000-000-0000 or 000-000-0000x000

  • III. LA Attorney

    Lead Agency (LA) Information cont.
  • ex: 000-000-0000 or 000-000-0000x000

  • IV. The due process hearing will be held at the following address (to be completed by the LA):

    Lead Agency (LA) Information cont.
  • Note: The hearing will be held at a time and place reasonably convenient to parents and the child involved.

  • Information About the Due Process Complaint (IDEA Cases Only)

    (If yes, the Office of Child Development and Early Learning (OCDEL) will be notified and will investigate the matter. Due process is not available when the issue pertains to non-implementation of a hearing officer's decision.)

  • Information About Due Process Complaint

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