Otherwise, copy and paste the information below into the body of your empty email form, fill it out, and mail it to:

FAMILY INFORMATION:

YOUR NAME  _____________________________ SPOUSE/PARTNER  _____________________

ADDRESS ____________________________________________________________________

CITY  ______________________________ STATE     __________ ZIP   _______________

EMAIL  _____________________________________

PHONE (DAY) _________________________ PHONE (EVE)  ___________________________

BEST TIME TO CALL? ________________________ CAN WE LEAVE A MESSAGE?     _ YES         _  NO

ANY NON-ENGLISH LANGUAGE(S) SPOKEN?  IF SO, WHICH?  __________________________

ORGANIZATION INFORMATION: if your contact with us is business related:
OCCUPATION  ________________________________ , FAX #__________________________ )

ABOUT YOUR CHILDREN: TOTAL # OF CHILDREN _________ # with DISABILITIES_______

NAME  _______________________________ _ MALE   _FEMALE        Birth date  _____________

NAME  ______________________________ _ MALE   _ FEMALE       Birth date   _____________

NAME  _______________________________ _ MALE   _ FEMALE       Birth date   _____________

NAME  _______________________________ _ MALE   _ FEMALE       Birth date  _____________

INFORMATION ABOUT YOUR CHILD WITH A DISABILITY

NAME  _____________________________________________

PRIMARY DISABILITY: ______________________________ Genetic? __ yes     __ no

OTHER ISSUES OR DISABILITIES: _____________________________________________

? DO YOU HAVE ANY SPECIAL CONCERNS? ____________________________________________

? WHAT WOULD YOU LIKE US TO KNOW ABOUT YOUR CHILD? ____________________________

Do you want to be included in FAMILY FACULTY INSTITUTE?  Yes____  No____

DO YOU WANT A ONE-TO-ONE MATCH?   Yes____   No____
Optional- we can get this information in our phone call to you or you can fill this out now:
The information below is requested to better enable us to match you with a newly-referred family.  With our statewide expansion we have computerized our system of matching parents.  All information is strictly confidential and is used expressly for matching purposes.  If your significant other has agreed to assist in the matching, please have them sign below as well.
? FAMILY CHARACTERISTICS WHICH MIGHT HELP US WITH A MATCH:  ____________________
? ANY SPECIAL CONCERNS OR REQUESTS REGARDING YOUR MATCH:  _______________________
HAVE YOU HAD EXPERIENCE WITH ANY OF THE FOLLOWING:
Please read through the list and then check all that apply:

__ Assistive Tech/Adaptive Equipment __ Adoption Issues __ Advocacy ____________________ __ Allergies______________________ __ Attachment Disorders __ Bed Wetting __ Bereavement __ Bilingual __ Botox Injection __ Brain Bleeds __ Surgery ___________________ __ Breast Feeding __ Broviac Line for Medication __ Catheterization __ Challenging Behavior __ Chronic Illness __ Chronic Pain __ Cognitive Delay __ Communication Issues _____________ __ CSHN/CDC __ Day Care __ Developmental Disability Issues __ Diversity Awareness __ Early Intervention __ Education Issues __ EEE __ Emotional Disorders __ ENT __ Feeding Issues ______________ __ Financial Planning

__ Fine Motor Delay __ FITP __ Fundraising __ GI Problems __ Gifted & Talented __ Grant Writing __ Health Care Financing ___________ __ Hearing Impairment __ Hearing Loss __ Hematology __ High Risk Pregnancy __ Home Schooling __ Hospitalizaitons __ Housing/Relocation __ Human Services __ Immobility __ Individual Assistant __ Legal/Parental Issues __ Medicaid / Waivers __ Medical Insurance __ Mental Health Issues __ Nasal Tubing __ NICU __ Nursing Care __ Oncology __ OT __ Parenting __ Personal Care Services __ PT __ Prematurity

__ Program Participation ___________ __ Public Health Services __ Resources __ Respite __ School Issues __ Shunt __ Sleep Issues __ Social Skills Issues __ Special Education __ Speech & Language __ Sports __ SRS __ SSI __ Susbstance Abuse __ Support Groups __ Terminal Illness __ Toileting Issues __ Trach __ Transition __ Twins __ Upper Respiratory __ VT Autism Society __ Visual Problems __ Weight Loss __ Written Language Disability ADDITIONAL INFORMATION / EXPERIENCE / COMMENTS:

 
 

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