Early Intervention Due Process Request Form (English) – Accessible Home Due Process Early Intervention Due Process Request Form (English) – Accessible Early Intervention Due Process Request Form (English) - Accessible Date of written request from parent(s):* MM slash DD slash YYYY Name of Child:* First Last Date of Birth:* MM slash DD slash YYYY Gender: Male Female Exceptionality(ies): Autism Deaf-Blindness Developmental Delay Emotional Disturbance Gifted Hearing Impairment (including Deafness) Intellectual Disability Multiple Disabilities Not eligible Orthopedic Impairment Other Health Impairment Protected Handicapped Specific Learning Disability Speech or Language Impairment Thought to have disabilities Thought to be gifted Traumatic Brain Injury Visual Impairment (including Blindness) County MH/ID Office:* Name of County MH/ID Contact Person: First Last Title: Address:Phoneex: 000-000-0000 or 000-000-0000x000Cell Phoneex: 000-000-0000 or 000-000-0000x000Email: Fax:ex: 000-000-0000County Legal RepresentativeName: Address:Phone:ex: 000-000-0000 or 000-000-0000x000Cell Phone:ex: 000-000-0000 or 000-000-0000x000Email: Fax:ex: 000-000-0000 Schedule hearing with: County MH/ID Contact Person Legal Representative Parent(s) InformationName(s):* Address:*Home Phone:*ex: 000-000-0000 or 000-000-0000x000Cell Phone:ex: 000-000-0000 or 000-000-0000x000Work Phone:ex: 000-000-0000 or 000-000-0000x000Email: Parent Representative InformationParent representative: Insert the name or “None”Title: Address:Phone:ex: 000-000-0000 or 000-000-0000x000Email: Fax:ex: 000-000-0000Schedule hearing with: Parent(s) Representative Reason for hearing:*Time of Hearing Preferred: 9:00 am - 12:00 pm 1:00 pm - 4:00 pm 5:00 pm - 7:00 pm Type of hearing: Open to the Public Closed (participants only) Language preferred by the parents: Alternative mode of communication: County MH/ID office has provided a site for the hearing accessible for individuals with disabilities at the following address:Please include a Google Maps link to the site of the hearing: Paste URL for Google Map here Name:* First Last Email:* Phone:*ex: 000-000-0000 or 000-000-0000x000CAPTCHA
