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PRTF Contact Form

*Please allow 1 week for a response.

Name

Relationship to Child

Email

Phone

Message

Student Information

Age

Sex

IEP Designation

IQ and Academic Level

Does the child have a formal diagnosis of an intellectual or developmental disability?

Please list diagnosis:

Please explain any medical conditions:

Please explain other mental health issues

State Student Resides In

Current Placement

Anticipated Funding Source

Private Pay School/IDEA funded Children & Family Services Organization Dept. of Disabilities/Regional Center Other

Insurance

Further information