Caller Name:Student Name:

EQUIP FOR EQUALITY’S SPECIAL EDUCATION HELPLINE QUESTIONNAIRE

1)Please complete the Helpline Questionnaire on pages 1-7.

2)If the student is 14.5 and older, please complete the transition questions on pages 8.

3)If the caller speaks a language other than English, please complete the translation questions on page 9.

Date:

Time:

Student’s Information
Name
Date of birth & age
Mailing address
Telephone number(s)
E-mail address
Where does the student live?
[choices: parental home, foster home, residential school, detention center, state operated facility, CILA, other]
Student’s racial background/ethnicity
What grade is the student in?
For our statistics and grant reporting, what is the number of people in the household?
What is the family income?
Source?
Caller’s Information
Name
Mailing Address
Telephone number(s)
E-mail Address
What is your relationship to the student?
Are you a registered voter?
If no, would you like our office to send you a voter registration packet?
How did you hear about EFE? (If a provider (i.e. social worker, counselor, psychiatrist), please list the name of the agency/organization the person works for.)
Preferred method of contact? / Phone, Email, Postal Mail
Is anyone in the student’s family currently serving on active duty in the U.S. military?
What do you think is the highest unmet legal need for people with disabilities in Illinois? / Special Education Rights for Children
Freedom from Abuse & Neglect
Quality of Services
Equal Employment Opportunities
Equal Housing Opportunities
Access to Public Services
Access to Private Businesses
Access to Transportation
Getting out of Institutions
Rights to Make own Life Decisions
Other (please specify):
Caller chose not to answer
Conflict Questions
Are you involved in any lawsuits?
If yes: What type?
Who is it against?
Who represents you and the other party?
Prior Legal Representation
Have you worked with an attorney or advocate for a school related matter? (If yes, indicate name.)
Why aren’t you working with that person now?
Would you sign a release so we could talk to your former lawyer/advocate?
Adverse Party
Name of school & district the student currently attends
Is this a Charter School?
If yes:
  • Have you ever been told to go to a different school or that the charter school could not serve your child?
  • Was that in writing?

Student’s Disability/Needs and Educational History
Disability
(If any type of mental illness, ask the following questions and please request that the caller provide documentation of the student’s mental illness:
1)Has a mental health professional determined that your student has a significant mental illness or emotional impairment that significantly impacts daily life activities?
2)Is your student’s issue at school related to his/her mental illness?
3)Is your student’s mental illness part of his/her IEP?
4)What type of mental health professional diagnosed your child’s mental illness (pediatrician, psychiatrist, psychologist, social worker, etc)?
5)When did the mental health professional diagnose your child?
6)Do you have documentation of this diagnosis?
If the caller says YES, please say the following statement “Equip for Equality receives federal funding to help people with disabilities and one of our funders requires us to ask for documentation of your child’s diagnosis. While we have not agreed to represent you, we would appreciate if you could provide us with paperwork documenting your child’s diagnosis.”
For students 10 and over: Which of the following six areas are substantially impacted by the student’s disability? Does the disability impact:
Learning
Mobility (the ability to move around)
Self-direction
(age appropriate judgment skills)
Language and Communication (the ability to express himself/herself)
Will the disability impact your child’s ability to live independently as an adult?
Will the disability impact your child’s ability to support himself/herself as an adult?
Is your child receiving special education services?
Does your child currently have an IEP or 504 plan? (If yes, which one?)
Date of last IEP/504 meeting
Date of next scheduled IEP/504 meeting
Does your child have a Behavior Intervention Plan (BIP)?
Has your child been suspended? If yes, about how many times?
Is the school trying to expel your child?
If yes:
  • Did the school hold a meeting to talk about whether your child’s behavior is related to his/her disability? (This meeting is called a manifestation determination review.)
  • When was the meeting?
  • What was the decision?

Has your child ever been restrained at school?
If yes:
  • When?
If within the last two years:
  • What happened?
Restrained: held against will (eg: held down on ground, against a wall, tied to chair, or held in someone’s lap)
Has your child ever been secluded at school?
If yes:
  • When?
If within the last two years:
  • What happened?
Secluded: placed in room alone with a door that is/could be closed
Have you filed a request for a due process hearing?
If yes:
  • When?
  • Who is the hearing officer?
  • When is your next phone call with the hearing officer?
A due process hearing is an administrative hearing, similar to a trial.
Are you working with any outside providers? (i.e. therapist, occupational therapist, speech therapist, social worker, psychologist, psychiatrist)
If so, with whom are you working?
Reason for Calling the Helpline
Provide a detailed explanation of the current problem that caused you to call EFE, including what you are asking of EFE, and your specific goal.
Please make your goal as specific as possible.
If the student with a disability is a teenager, would the student agree with your goal? Can we talk to the teenager?
Is there anything else we should know about the student or what is going on at school?
TRANSITION QUESTIONS
Please ask these questions of students between the ages of 14 and 21.
Does the student have a transition plan in his or her IEP?
A transition plan is supposed to prepare the student for adulthood.
Is the transition plan designed to prepare the student for independent living, employment, and/or further education?
Would you like more information or help with the student’s transition plan?
Has the student applied for DRS services?
If yes
Is the student receiving DRS services?
If no 
Equip for Equality has partnered with the Department of Rehabilitation Services (DRS) to inform students over 14 1/2and their families about transition services from DRS, such as job training, payment for community and four year college, and help with employment. I will be sending you some information about DRS transition services that you should review and contact me with any questions.
Translation Questions
Please ask these questions if the parent speaks a language other than English.
Was there an interpreter at the last IEP meeting? Do you know who the interpreter was? (name/qualification, job; ie - Principal, secretary)
Is the IEP ever written in another language? Have you asked?
Do any school staff communicate with parents in another language? If so who/how/when?
Do any school letters come home in a language other than English?
Have language concerns every caused problems with your child’s education or special education? If so, what happened?

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