Contact

I’d Love to Hear From You

I am always happy to hear from you by phone or email but the information I ask for in the intake form is helpful to have in advance of a first conversation. I look forward to working with you and your child. Items marked with a * are required.

(248) 514-2101
marcielipsitt@outlook.com

"*" indicates required fields

Name

First Last

Phone * Required

Cell Phone

Preferred Contact Number * Required

Phone Number

Cell Phone

Relation to Student * Required

Parent

Guardian

Other

Custody/Guardianship Status

Name of Student (if you are comfortable providing that here)

Birthdate

Age * Required

School District

School

Currently has Individualized Education Program (IEP) * Required

Yes

No

Currently has a Section 504 plan * Required

Yes

No

Home Schooled

Yes

No

Private School

Yes

No

Current Issues, questions or problems to resolve:

Is this a referral?

Yes

No

If you answered yes, please provide a name.

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Email

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