GET STARTED HERE!

The most efficient way to know if your child can benefit from services is to complete our “Get Started Form.” This will guide our team of experts to best support you and your child and set them up for optimal success. Once submitted, you will be contacted by one of our friendly staff members to discuss the next steps or provide resources to assist in making the best decision or your child.

Student Information Form

Student Information

Student Name

First Name

Last Name

Date of Birth

YYYY

Age

School

Grade

Please tell us what grade the student is currently in

Parent (legal guardian) Information

Parent Name

First Name

Last Name

Phone

(###)

###

####

Insurance Information

Please tell us your current health insurance information *please note BCBS NE or NE Medicaid accepted

Insurance Carrier

Ins Member Name

Insurance Member ID#

Contextual Questions:

Please answer to the best of your ability. These questions help us best serve you and connect you with the appropriate services.

Program/Service you are interested in

Please tell us what program or services you are interested in for your student.

Interventions

Home School Groups

Simplistic Learning Academy

Assessments

Advocacy

I'm not sure, but want to know more

Does your child have

An Individual Learning Program

504 Plan

I'm not sure

Has your child received previous interventions and/or services?

Has your child been evaluated? If yes, please explain.

Please share your child’s strengths and interests.

Please share your concerns, classroom teacher/school concerns.

Do you have concerns with your child’s language/speech? Do they or have they previously received speech services?

Please provide any additional information that will help us to support your child.

*Submit a student intake form and one of our staff members will contact you within two days to discuss any questions you might have and solutions, options, and further support that could be provided.

CONTACT INFO

If you would like to contact us please find our general contact information below. Please leave a phone number in the message so we can reach out to you at our earliest convenience. We look forward to talking with you soon!

Email
simplisticsolutions.ne@gmail.com

Phone and Fax

402-289-5961

Address

2949 N 204th Street, Suite 105

Elkhorn, NE 68022

GET STARTED HERE!

CONTACT INFO

Location

Contact us