Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

DISABILITIES PARENT QUESTIONNAIRE HEAD START/ECEAP

This questionnaire is for parents whose Head Start/ECEAP child is currently receiving services or in the process of being evaluated by the School District and not referred by Head Start/ECEAP.

Child’s Name: Click or tap here to enter text. Date: Click or tap to enter a date.

Area of Disability: Click or tap here to enter text.

Parent/Guardian Name: Click or tap here to enter text. Phone Number: Click or tap here to enter text.

Staff Name: Click or tap here to enter text.

I need more information about my child’s special need: Choose an item.

My child’s special need is: Click or tap here to enter text.

Specific information needed: Click or tap here to enter text.

I need more information about the school district’s process: Choose an item.

☐ Evaluation

☐ Individual Education Plan (IEP)

☐ Other: Click or tap here to enter text.

I need more information about:

☐ Supplemental Security Income (SSI)

☐ Division of Developmental Disabilities

☐ Health Information

Specific Need: Click or tap here to enter text.

☐ Support Groups for Parents

For children receiving school district special services:

I know the name of my child’s special education teacher and/or therapist: Choose an item.

I know how to get in touch with my child’s special education teacher and/or therapist Choose an item.

Other information needed: Click or tap here to enter text.