Family Consultation Application

We’re excited to learn more about you!

To complete the next step in creating your personalized plan, please complete the below application and submit the $150 consultation fee.

Once we have received your application and payment, we’ll contact you to begin the next step in the process: a 60-minute get-to-know you meeting.

If you have any questions as you complete the application, please email Executive Director Jennifer Roccanti at jennifer@onmyownofmi.org.

One-On-One Consultation Application

Step 1 of 3

Student First + Last Name*
Student Date of Birth*
Student Gender Identity*
Student Grade Level*
Student School Name:*
Student Developmental Disability*
Do your student currently have an IEP, 504 plan or annual plan of service?*
- Yes
- No

Parent / Guardian #1 First + Last Name*
Parent / Guardian #1 Relationship to Student*
Parent / Guardian #1 Address (please include street, city, state + zip code)*
Parent / Guardian #1 Email Address
Parent / Guardian #1 Phone Number*
Parent / Guardian #2 First + Last Name
Parent / Guardian #2 Relationship to Student
Parent / Guardian #2 Address (please include street, city, state + zip code)
Parent / Guardian #2 Email Address
Parent / Guardian #2 Phone Number

To help us have a great experience, you should also know this about me:
I heard about one-on-one family consultations from:

Make $150 Payment