Family & Student Information Form

This form is confidential and only used to prepare for your Intro Call. It's not an application and there's no commitment attached to filling it out.

Parent / Guardian Information

Your Name *

Email Address *

Phone Number

Where are you located? *

Student Information

Student's First Name *

Student's Age & Grade *

School District or School Name *

School Type * Charter schools follow slightly different rules than public districts, so this helps us prepare correctly.

Where are things right now with special education services? *

Has an Individualized Education Program (IEP) Has a 504 Plan Currently being evaluated Requesting a first evaluation Not sure yet, just starting to ask questions

Area of concern or diagnosis, if known

Get to Know Your Child

This is the part I look forward to reading the most. Parents of kids who learn differently spend so much time on forms that only ask about challenges. These three are just for you to brag, and they're completely optional.

What do you want me to know about your child as a person?

What is your child really good at or passionate about?

What does a really good day look like for your child?

Your Situation

Any upcoming meeting or deadline we should know about?

What's going on right now? What would you like help with? *

How did you hear about Berry Empowered?

Your information is kept completely confidential and will never be shared. We'll follow up within 2 business days. Want to talk sooner? Book your free 20-minute Intro Call online.

Family & Student Information Form

We've got it.