Request for Mediation - Early Intervention - William H. Bowen School of Law

Is this a request for:(Required)

Early Intervention Mediation

Facilitated Individualized Family Service Plan (FIFSP) meeting

Requesting party?

Parent, adult, or guardian

Service Coordinator

EI Provider

Child's name(Required)

First Last

Child's date of birth(Required)

Who has custody of child?(Required)

Please select the correct description of the parents' relationship to the child.

Parent or guardian name

Is this the person the child lives with most of the time?

Yes

Address

Street Address City State ZIP Code

Home phone

Work phone

Cell phone

Phone number where you'd prefer to be contacted(Required)

How do you prefer to be contacted?(Required)

Phone

Mail

Parent or guardian name

Is this the parent the student lives with most of the time?

Yes

Address

Street Address City State ZIP Code

Home phone

Work phone

Cell phone

Phone number where you'd prefer to be contacted

How do you prefer to be contacted?

Phone

Mail

Child and parent or guardian information

Is there an advocate?

Yes

Please list name and contact information.

Service Coordinator(Required)

EI Provider Name(Required)

Summary of issues to be discussed:(Required)

Who are the key people who should attend mediation or facilitation, their jobs, and how to contact them?

For instance, individuals who must attend FIFSP meeting are: therapists, service coordinator, and parent/guardian. Others who may attend include: others who work with your child, like a daycare provider, or anyone the family wants to include, such as other family members or an advocate.

Are there any other circumstances about the child that we should be aware of?

If this meeting is involving a facilitated IFSP instead of a mediation, please answer the following questions:

Date and time of proposed facilitated IFSP?(Required)

Please list at least three days and times that would be best for you to attend a facilitation session.

Type of IFPS

Initial

Bi-annual (6 month review)

Annual

Other (quarterly or review at parent request)

Date of last IFPS meeting

Are there evaluation results that need to be shared prior to the meeting?

Yes

What items need to be shared prior to the meeting?

You may upload the evaluation results if you wish.

Drop files here or

Accepted file types: pdf, Max. file size: 49 MB.

What concerns are you expecting to share during the meeting?

Are there any other circumstances about the child that we should be aware of?

How did you hear about this program?(Required)

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Request for Mediation – Early Intervention

Child and parent or guardian information

If this meeting is involving a facilitated IFSP instead of a mediation, please answer the following questions:

Contact

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