Parent/Guardian Inquiry Form
A member of our team will contact you within 3 business days to discuss your inquiry, available services, and appropriate next steps.
Parent/Guardian information
Who is completing this form?
*
Please Select
Parent
Legal Guardian/Foster
Family Member
Other
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Please Select
Phone Call
Email
Text Message
No preference
Best Days/Times for Follow-Up
*
Individual Needing Support
Full Name or Initials
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City of Residence
*
Does the individual currently have an Individualized Education Program (IEP) or 504 plan?
*
Please Select
Yes
No
Unsure
Not Applicable
Is the individual currently receiving behavioral health, developmental, or community-based services?
*
Please Select
Yes
No
Unsure
What type of support or services are you interested in?*
*
Community Living Supports (CLS)
Respite Services
Therapy
Behavioral Health Assessment
Psychiatric Evaluation
Psychological / Neuropsychological Testing
Case Management
Parent / Family Support or Training
School-Based Behavioral Health Services
Developmental Screening
Not Sure / Need Help Determining Services
Other
Does the individual currently have Medicaid?
*
Yes
No
Needs, Current Supports, or Additional Information (optional)
Please share any current concerns, diagnoses, providers, supports, or other information that may help us better understand your inquiry.
Needs & Current Supports
Preferred Contact Method
*
Phone Call
Email
Text Message
No preference
Does the individual currently have an Individualized Education Program (IEP)?
*
Yes
No
Unsure
Not Applicable
Submit
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