Parent Intake Form

Thank you for your interest in the PREP e-Clinic for parents in California, New York, Mississippi, and Louisiana. Please fill out the following intake form to the best of your ability. Required information is marked with an asterisk (*). All other questions are optional.

If you have questions on more than one child, please fill out a new intake form for each child. Every effort will be made to pair the parent with the same volunteer if possible.

If you match all service requirements, a volunteer will contact you to set up an appointment within 2 weeks.

Required information is marked with an asterisk (*)

Guardian Information

Email address*

I affirm that my current income is limited, and as a result I need PREP's services because I otherwise could not afford a legal consultation on this issue*

Yes
No

First Name*

Last Name*

Street Address*

City*

State*

Zip Code

Phone*

Preferred Communication Method*

Email
Phone
Mail
Video Chat

Do you want to video chat with volunteer? (no personal account required)*

Yes
No
Maybe

Preferred Language*

English
Spanish

Preferred Times of Contact*

Weekday Mornings
Weekday Afternoons
Weekday Evenings
Weekend Mornings
Weekend Afternoons
Weekend Evenings
Other

Student Information

First Name*

Last Name*

Birth Date*

Race

Special needs

Student's Preferred Language*

English
Spanish

Student's Grade Level*

School

School Name*

School District*

Type of School (if known)

Public
Private
Charter

Concerns*

Please explain your concern(s)*

Have you spoken with anyone about these concerns?*

Yes
No

What was the outcome?

If there is an important deadline or date related to the issue described, please enter it here

Is there anything else that you would like to share with PREP at this time?

USER AGREEMENT

The Parental Readiness and Empowerment Program (“PREP”) provides free legal consultations to parents through the E-Clinic to assist the parent in advocating for their child’s educational rights and needs in California, New York, or Mississippi (the “Consultation”). This agreement is between the parent/guardian filling out this form, PREP (a Lawyers’ Committee for Civil Rights Under Law program), and the volunteers and partners of PREP providing pro bono legal support.

To receive a Consultation, a parent must acknowledge and agree to the following terms:

Limits of Work

I understand that PREP is only agreeing to provide me with a legal consultation on my issue and will not represent me. The Consultation does not create an attorney-client relationship. The PREP consultation will only provide basic information and advice related to PREP’s issue areas of special education, school discipline, English learners, and discrimination issues.

I understand and agree that PREP will not provide a consultation to me if the issue is related to:

A criminal investigation or criminal charges or juvenile delinquency matters.
If the parent already has a lawyer representing them on that issue.
A child’s rights in private school.
In-person assistance during any school meeting or formal hearing.
Formal hearing or mediation process, or the formal complaint process.

Ending the Consultation

I understand the consultation ends once PREP has:

Provided me with basic legal information and advice related to my concern.
Offered to provide me with a completed Action Plan by email, text, or mail.

I understand the Consultation may also end if:

I choose to terminate this Agreement at any time.
PREP tries to contact me two times and I do not respond within one week after the second message.

I understand that my conversations may sometimes occur with a paralegal volunteer, law school student, or individual not barred in my state (California, New York, or Mississippi); but, any such conversations will be supervised by a lawyer who is barred to practice law in my state (California, New York, or Mississippi).

Confidentiality

I understand that all documents and information submitted to PREP and discussed during the Consultation will be treated as confidential between PREP, the volunteer, and me, unless I agree to share confidential information.

I understand that PREP only maintains electronic files related to my case, and such files will be kept for at least six years.

Fees & Costs

I understand that there is no cost for the Consultation. All services provided through the e-clinic are free.

Parent Communication

I understand that my responsibilities to communicate with PREP include:

• Responding to PREP when they contact me.
• Sharing any change in personal contact information.
• Sharing information and documents that I want PREP to consider during my Consultation. I understand that PREP will not request documents from other individuals or entities on my behalf.

I understand that all communications for the Consultation will be done through phone, email, video, or text. PREP will use my preferred method of communication whenever possible. I am fully comfortable and capable of communicating through these methods.

I understand that PREP will make all efforts to respond to me as soon as possible, but that response times will depend on volunteer resources and availability. PREP makes a committed effort to contact me within two weeks of submitting this form to schedule my first appointment.

Declining to Advise

I understand that PREP cannot advise me if:

(1) PREP is required to end involvement because of a potential conflict of interest, such as claims against other parents.

(2) PREP determines that I have no legal right to my desired outcome;

(3) There is too little information for PREP to capably advise me;

(4) My issue falls outside PREP’s scope of services;

(5) For any other reason in the state's Rules of Professional Conduct (California, New York, or Mississippi).

I agree that:

• I am over 18 years old and I am a parent or legal guardian of a child attending a public school (grades pre-K to 12).

• All the information provided to PREP is and will be true and accurate.

• I have read this Agreement, understand the terms, and agree to all terms.

(If you don't agree, you will not be contacted)

Yes
No

Please type your name below to indicate you agree with these terms.*