Initial Client Information Form

Please complete the Client Information Form below to get started and Dr. Eccleston will contact you within one business day.

* Indicates required field

CHILD'S INFORMATION

Child's Legal Name *

Preferred Name/Nickname

Preferred pronoun

Child's Date of Birth *

School System/County *

Other School System

REFERRAL/REQUESTED INFO

Services Requested *

How did you hear about Eccleston Education Consulting? *

If referred by an attorney, physician, service professional, organization, school, etc., please provide the name of the individual, firm, or organization

PRIMARY CONTACT INFO

Primary Contact First & Last Name *

Who is providing information? *

Primary Contact Cell Phone *

Primary Contact Home/Work Phone

Primary Contact Email *

Address

Street Address

City

State

Postal Code

SECONDARY CONTACT INFO

This may include spouse, Guardian, Family Member, Friend, Attorney, Physician, or Educator, etc.

Secondary Contact First & Last Name

Secondary Contact Cell Phone

Secondary Contact Home Phone

Secondary Contact Email

Secondary Contact Street Address

SCHOOL INFORMATION

Child's Current Grade *

Current School Name *

Neighborhood School Name

Type of School *

Date of last school meeting

Date of upcoming school meeting

Time of upcoming school meeting

IEP/504 INFORMATION

Does child have a current IEP? *

Yes

Does child have a current Section 504 Plan? *

Yes

Other relevant medical or educational diagnosis

Briefly describe why you are contacting Dr. Eccleston and the overall current concerns regarding your child’s education. *

CONSENT & SUBMISSION

By checking this box, I accept the following Terms and Conditions:

This information is provided to Eccleston Education Consulting for the purpose of beginning the intake process for prospective clients. Eccleston Education Consulting will not disclose, divulge, or reveal any confidential information regarding the primary contact, secondary contact, or child without specific written consent or as required by legal process.

By checking this box, I consent to receive email communications from Eccleston Education Consulting, including appointment reminders, newsletters, and account notifications. You may unsubscribe at any time by clicking the unsubscribe link in any email.

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