Fill - Dear Parents, The packet enclosed includes several forms

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! !

Dear Parents,

The packet enclosed includes several forms for you to complete and return before your appointment is

scheduled. Receipt of this information is a part of the consultation process and allows us to review you child’s

needs and prepare for our first meeting.

ALL forms MUST be received before any appointments are

scheduled

. Please note that if you decide to proceed, you should return this packet as soon as possible since

referrals are accepted on a first come first serve basis. As soon as we receive the packet, you will be contacted

unless otherwise specified. If you receive this packet as PDF file, please complete and return by regular US

mail, scan-pdf, or fax. If you wish to fax the forms to us, do so at 301-933-3062. Once received, we can set

up your appointment.

Additional documents that would be helpful to review in advance include medical, school, therapy,

educational reports and COMPLETE IEP,s if your child currently has one. These documents can be helpful in

gathering the necessary information to understand the full scope of your child’s needs. Please forward those

with the packet.

Records dating back to two years are adequate. If you have any questions about the

completion of these forms, please call 301-758-4275. I am located at

10605 Concord St, SUITE 102

Kensington, MD.

For any appointments, the

PASSCODE INTO THE SUITE IS 8255

If you are seeking consultation services, please read all statements of terms, fees and services

carefully. It carefully outlines the process and payment requirements. Payment will be required at the time of

the first meeting for whichever service you desire. This includes payment at the hourly rate or the full retainer

fee if you are seeking a detailed consultation.

At any time, please contact us for clarification of the services and fees.

For MAIL, send to:

Suzanne Keith Blattner, M.S, Ed.S

10605 Concord St., Suite 102

Kensington, Maryland 20895

Or, send electronically to

Skb.edu@mac.com

Thank you for your cooperation and I look forward to meeting you.

ˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆˆ

Suzanne Keith Blattner, Ed.S. & Associates

Special Education Consultation, Advocacy, Educational Therapy and Academic Tutoring

Intake Referral Form

Name: _____________________________________________________________________________________

Date of Birth:________________________________________________________________________________

Parents/ Caregivers:

Parent 1:____________________________________________________________________________________

Parent 2:____________________________________________________________________________________

Street Address:______________________________________________________________________________

City:_________________________________________ State: __________________ Zip: __________________

Phone Numbers: H: ____________________________________

Work (parent 1) _______________________________________

Work (parent 2) _______________________________________

E-Mail Address 1:

_____________________________________

Email Address 2 : _____________________________________

Cell#1___________________________________________#2:_____________________________________________

Current School Placement or Program:_______________________________________________________________________

Current Grade:______________________

Describe your concerns and primary referral reasons:

_________________________________________________________________________________________

___________________________________________________________

_________________________________

_________________________________________________________________________________________________

Suzanne Keith Blattner, Ed.S. & Associates

Special Education Consultation, Advocacy, Educational Therapy and Academic Tutoring

_________________________________________________________________________________________________

Briefly describe pertinent medical history (or attach reports that will summarize the

information):

_________________________________________________________________________________________

Briefly describe pertinent educational history:

_________________________________________________________________________________________________

________________________________________________________________________________________________

Describe current health status:

_________________________________________________________________________________________

_________________________________

Current Medications (name and dosage)

_________________________________________________________________________________________

Pediatrician:__________________________________________________________PH:_________________________

Developmental Pediatrician:___________________________________________PH:_________________________

Other Physicians (name and ph):

Name:_______________________________________________________________PH:_________________________

STATEMENT OF EDUCATIONAL CONSULTING SERVICES

Educational Consulting services involve a broad menu of services available to families. In all cases, a

full paperwork review and observation or meeting with the student is necessary. This is to help us get to know

your child in an educational setting and speak with staff if permissible.

In the case of assisting families with special education options, we act as INDEPENDENT and

OBJECTIVE consultants in order to help you make the best possible decision for your child. We CANNOT

accept clients whose goal is to simply endorse a decision that has already been made. We will always enlist

your opinions and thoughts about your child, his or her needs and background about educational experiences

that have been successful and those that have not. However, in the case of a special education placement, the

process is governed by federal and state regulations with the IEP being the driving force determining

appropriateness.

As part of our assessment and review, we consider all possible options and will assist you with the

process through advocacy to obtain those services. However, there are NO guarantees. In some cases, parents

must also engage attorneys if the legal proceedings go beyond an IEP meeting. In some cases, we can

accompany a parent to mediation.

The process for helping families identify independent private schools also involves review of all

documents that assist us with getting to know your child. We will guide you in the attainment of independent

evaluations and the submission of applications and appropriate paperwork. We will identify schools that we

feel are the best fit once all the information is made available to us. Again, there are no guarantees with regard

to acceptance. The process is dependent on many factors which will be explained when you come for a parent

conference.

The process for all consultations typically involves a parent/caregiver intake meeting. At this time, we

will set goals for the consultations, reaffirm our role and answer ANY questions you may have. This is

followed by a school observation or an office visit (on occasion for very young children a home visit). We assist

you with gathering the necessary documentation and share our observations and assessments of your child’s

strengths and needs as it relates to their current and future education. If requested, a report or summary can

be generated (billed at the hourly rate). We will attend meetings if requested. We only ask that we discuss

scheduling in advance before confirming meeting dates established by other parties.

If you have ANY questions regarding the process, please feel free to call or email Suzie Blattner at

skb.edu@mac.com.

I ____________________________________________________ , acknowledge receipt of and agree to the terms

of the educational consultation outlined above.

Print Name:

______________________________________________________________ ________________________________

Signature date

Suzanne Keith Blattner, Ed.S. & Associates

Special Education Consultation, Advocacy, Educational Therapy and Academic Tutoring

!

Statement of Fees

!

Educational Consultation and Advocacy: $250.00 per hour

This fee includes record reviews, intake parent meetings, school observations, office visits with student, parents or

guardians, telephone and email consultation with client and other specialists, IEP consultations, and parent consultations,

conferences and written reports. Travel time is calculated from my home or office (whichever is closer) to the location of

the meeting or observation.

Expert Testimony $300.00 per hour

This fee includes all time related to any administrative due process matter including

Preparation and oral and written testimony. This includes both mediation and hearings.

Payment OPTIONS:

Hourly

: Requires Credit Card authorization form (in packet). This option includes monthly billing (end of month) for all

billable hours related to any and all services described above. Client will receive a statement and credit card receipt. If

you prefer to pay by check, payment is due at the time services are rendered plus a retainer for any agreed to services.

Credit Card Payment:

This option is available for monthly payment. In this case, no retainer is required for a full educational consultation

service. Please note, if a credit card is DENIED for any reason during processing, there will be an additional $25 charge.

Please be sure to keep Credit Card records current. Although the Credit Card form is enclosed in this packet, you may

bring this form to our first meeting.

PayPal Payment

: Direct payment to my PayPal account is an option. Please contact us if you wish to make payment

through PayPal. The same terms apply. Payment is due at the time the invoice is emailed.

Cancellation Policy

Cancellations made less than 24 hours in advance are billed at the full rate if the time slot cannot be filled.

This policy is

strictly enforced.

If your child becomes ill during the night, please call by 7:00 AM the morning of your appointment and

leave a message with your child’s tutor.

IMPORTANT:

Payment is expected upon receipt of your invoice with a grace period of

NO LONGER

than

15 days from the date of the

invoice.

A late charge of $25.00 along with a finance charge of 1.5% will be calculated daily on the unpaid balance on

the 16th day from the date of the invoice.

This policy is strictly enforced

.

Payment not received within a timely fashion

will result in termination of all services. However, the client will be responsible for all fees incurred up to an including the

date of termination

.

Suzanne Keith Blattner, Ed.S. & Associates

Special Education Consultation, Advocacy, Educational Therapy and Academic Tutoring

Agreement to Terms of Payment and Services

I ___________________________________________ acknowledge and accept full responsibility for payment of

all services rendered to my son/daughter by Suzanne Keith Blattner, M.S. Ed, Ed.S. and her associates. I

acknowledge that I have received written explanation of the fee schedule, payment terms, retainer

requirement, the cancellation policy and statement of services and am in agreement with all.

I understand that health insurance policies are an arrangement between myself and the insurance company,

that all services rendered to my child are charged directly to me, and that I am personally responsible for

payment. I understand that agreements regarding fee schedules, changes for canceled appointments and late

payments are between Suzanne Keith Blattner and me and are not related to potential insurance coverage. I

understand that Suzanne Keith Blattner will assist me in completing forms to aid in collecting insurance

benefits ONLY for educational services that are billable. I agree to the release by Suzanne Keith Blattner of

any information that is requested by my insurance company.

I agree to retain the services of Suzanne Keith Blattner M.S. Ed and associate (if applicable) to assist in

educational placement and planning for my child. I understand that the process does not offer a guarantee of

a particular placement, program or outcome.

___________________________________________________

Signature of Parent or Legal guardian

___________________________________________________

Print Name

____________________________________________

Date

Suzanne Keith Blattner, Ed.S. & Associates

Special Education Consultation, Advocacy, Educational Therapy and Academic Tutoring

Suzanne Keith Blattner, Ed.S

Special Education Consultant

T: (301)-758-4275

Fax: (!301)-933-3062

E- skb.edu@mac.com

Credit Card/ Debit Transaction Processing Authorization Form

_____ Yes,%I%would%like%you%to%automatically%charge%my%credit%card%for%services%rendered%each%

month.!

Card%Type:%%%%%%%%%%%%%%%%________%Visa%%%%__________Master%Card%%__________AmEx%

% %

Number:%______________________________________________________________________________Exp.%Date______________!!

! !

3-digit!security!code!on!back!of!card______________%

%

Billing%Address%(REQUIRED)%

__________________________________________________________________%

(Street)%

% ________________________________%______________%%%%______________%

% % (City)% % % % % (State)% % % %%%%%(Zip)%

!

By! signing! this! Agreement,! and! marking! the! box! noted! above,! the! undersigned! does! hereby! agree! as!

follows:! (i)! the! undersigned! does! hereby! authorize! and! agree! that! Suzanne ! Blattner! and/or! its! duly! authorized!

agent!(the!“Company”)!has!the!right!from!time!to!time!to!charge!to!the!above!identified!credit!card!and /or!debit!

the! account!identified!above!any!and! all! amounts! that! are! owed! to! the! Company! and/or! its! consultants,! (ii)! the!

undersigned!agrees!that!its!signature!on!this!Agreement!shall!be!deemed!its!signature!on!any!sales!charge!receipt!

or! other! form! and! if! any! merchant! services,! credit! card! company,! or! bank! requests! to! view! the! undersigned!

signature! on! a! sales! charge! receipt! or! other! form,! the! Company! may! provide! such! company! with! a! copy! of! this!

Agreement!and!such!shall!be!deemed!conclusive!proof!that!the!undersigned!approved!and!authorized!the!charge!

and/or!debit!at!issue,!and!the!undersigned!does!hereby!waive!any!right!to!dispute!its!authorization!to!such!charge!

based!on!an!invalid!or!non-existent!signature.!!The!undersigned!understands!and!agrees!that!the!above!payment!

option! and! charges! or! debits! will! continue! each! month! for! services! rendered! by! the! Company! and/or! its!

consultants!until!such!time!as!the!undersigned!has!provided!written!notice!to!the!Company!to!stop!such!automatic!

charges!and/or!debits.!!The$undersigned$shall$be$fully$responsible$for$ensuring$that$it$has$sufficient$credit$

and/or$funds$to$cover$the$charges$or$debits,$and$shall$indemnify$the$Company$against$all$costs$incurred$as$

a$result$of$any$declined$charge$or$debit.!If#the#undersigned#does#not#notify#this#contractor#that#the#card#has#

been#lost,#stolen#or#will#be#declined#for#any#reason,#there#will#be#a#$25#charge.#####

!

AGREED%AND%ACCEPTED:%

Cardholders%Signature:_____________________________________________________________Date:____________________%

%

Print%Name%(as%it%appears%on%the%card):____________________________________________________________________%

%

*All!credit!cards!will!be!processed!at!the!beginning!of!each!month.!

**All!Debits!will!be!processed!at!the!beginning!of!each!month.!

!

I,______________________________________________________ authorize Suzanne Blattner to electronically mail paid

invoices in PDF file to the following email address________________________________________________________

!

CHECKLIST BEFORE FIRST APPOINTMENT:

Have you completed and sent the following?

¨

Intake Referral Form

¨

Authorization/ Release Form (can be completed at the time of the first

appointment)

¨

Agreement to Terms of Educational Consulting Services

¨

Agreement to Terms of Services and Payment

¨

Relevant Developmental or Medical Evaluations

¨

Relevant Educational documents including COMPLETE IEP’s from the past 2

years.

¨

Credit Card Authorization (can be submitted at the first appointment / intake

meeting)

Thank you.

When you come for your intake appointment, the passcode into our suite is 8255

I look forward to meeting you.

Suzie Blattner

!

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Fillable Dear Parents, The packet enclosed includes several forms

Fill Online, Printable, Fillable, Blank Dear Parents, The packet enclosed includes several forms Form

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