Raising Harts Family Support Request
Raising Harts has been given a meaningful opportunity to connect families in our autism community with direct support from MAR5 and A Voice for Mikey for high-need items such as assistive equipment, safety tools, and technology; as well as assistance in paying for therapies, assessments, and medical bills. Families may submit up to 4 items to be considered for funding.
Gather Your Information Before Submitting
Before continuing, please ensure you have all the links to the items you are requesting, as you will need to provide them below. Additionally, if you are seeking assistance in paying for therapy, assessment, and/or medical bills, please ensure you have invoices and payment links available, as payments will be made directly to providers.
Medical Insurance Requirement
If you are requesting any item that may be covered by insurance, like a Cubby Bed, you will need to go through insurance first. If you are denied, you can then submit a request for that item, along with documentation.
Planning for Total Project Costs
When submitting a request, we ask families to carefully consider the full scope of the project, including any additional costs beyond the item itself. While MAR5 and a Voice for Mikey funding may cover approved items, expenses such as installation, landscaping, maintenance, or other related services are not eligible for funding. Ensuring that you have a plan in place for these associated costs will help avoid delays or challenges after a request is approved.
Parent/Caregiver Information
Please note that the address provided is where items will be shipped.
Full Name
*
First Name
Last Name
I confirm this is my first time submitting a request.
*
Please Select
Yes, this is my first time submitting a request
No, I have a submitted a request before
If you have already had a request fulfilled, our goal is to reach as many families as possible and are grateful for your understanding that your additional request will not be funded at this time.
How did you hear about this initiative?
*
What is your relationship to Raising Harts?
*
Shipping Address
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have an autism diagnosis?
Please Select
Yes
No
Please briefly describe how this funding would assist your family and child (2–4 sentences)
*
Request 1: Please provide a detailed reason and description of the item or service you are requesting. Please include link for this item.
*
If this request is payment for a bill, please upload invoice here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Request 2: Please provide a detailed reason and description of the item or service you are requesting. Please include link for this item.
If this request is payment for a bill, please upload invoice here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Request 3: Please provide a detailed reason and description of the item or service you are requesting. Please include link for this item.
If this request is payment for a bill, please upload invoice here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Request 4: Please provide a detailed reason and description of the item or service you are requesting. Please include link for this item.
If this request is payment for a bill, please upload invoice here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like to sign up for the monthly Raising Harts newsletter?
*
Please Select
Yes! Sign me up please
I'm already on the list
Nah, I get too much email already
Form Name
Form Type
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