Initial Inquiry Form

Initial Inquiry Form

Please complete the following form to apply for potential enrollment at Excel Prep school. Once you have submitted the form, our team will evaluate your application and reach out with information on next steps.
Name of person completing application*

First NameMiddle NameLast NameSuffix
Phone number of person completing application*
Email of person completing application*
Relationship to child*

ParentLegal GuardianSpecial Education District School RepresentativeOther
How soon are you looking to enroll this child?*

As soon as possibleSummer termFall/Upcoming school year
Student Background Information
Student's Name*

First NameMiddle NameLast NameSuffix
Student's Date of Birth*

MonthDayYear
Gender*
Grade Level*
Primary Language*
Primary Language Used at Home*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name and Relationship of Who the Child Resides With*
Guardian Information
Primary Guardian Name*

First NameMiddle NameLast NameSuffix
Primary Guardian Phone Number*
Primary Guardian Email*
example@example.com
Primary Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Learning/Social History
Reason for referral, please select all that apply:*

AcademicDevelopmentalCommunicationSocialOther
Type of programming currently receiving:*

General educationResourceSelf-ContainedHomebound (District Placed)Homeschool (Parent Provided)Clinic (Not in School)Other
Name of current school
Name of current school district
Has this student ever received MTSS for academic or behavioral reasons?*

YesNoUnknown
Has this student ever been held back a grade?*

YesNoUnknown
Has there been any attendance concerns?*

YesNoUnknown
Has the child ever received ABA services in a clinic setting*

YesNoUnknown
Has the child ever received related services in a clinical setting? Check all that apply:*

OTSpeechPTCounselingFeeding TherapyOther
Please briefly describe current needs for this child:*
Please provide a brief description of the child's areas of strength (i.e., daily living skills, academics, communication, etc.)*
Please provide a brief description of areas in which the child struggles (i.e., daily living skills, academics, communication, etc.)*
Medical History
Primary Diagnosis*
Secondary Diagnosis (if applicable)
Has the child ever been hospitalized due to behavioral or emotional reasons?*

YesNoUnknown
Please list out any medications the child takes, including doses and times they are taken:
Example: Dextroamphetamine: 5 mg, takes it x2 daily at 8 am and 2:00 pm
Please list out any other important medical concerns we should be aware of:
Does the child have a seizure plan?*

YesNo
File Upload

Please upload the following files for review if they are available.
Upload IEP (if applicable)

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Upload 3-Year Evaluation IEP (if applicable)

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Upload BIP (if applicable)

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Upload Evaluation to Support Diagnosis

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Upload Grades/Progress Reports (if applicable)

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Upload Attendance Records (if applicable)

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Other Psych Related Services and Supports

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Should be Empty:

Initial Inquiry Form

Student Background Information

Guardian Information

Learning/Social History

Medical History

File Upload