Refer a family
Families and parents can self-refer or be referred to us by professionals in health care, social services and education.
How Do I Refer Families to Raising Special Kids?
1) Use the referral form (English and Spanish), 
Family Referral Form.pdf
2) Be sure to obtain the parent's signature (required).
3) Fax completed form to (602) 242-4306.
Download or print pdf of waiver/release or copy and paste the text below into your word processor
Family Waiver/Release of Information
Raising Special Kids provides support, information, resources, training and assistance to families of children with disabilities or special health care needs in Arizona. All programs and services are offered free of charge in both English and Spanish, at all ages and stages of a child’s development.
By providing the following information, you are giving Raising Special Kids permission to initiate contact with the family you are referring for services. Upon receiving your referral, the family will be contacted within 48 hours in most cases, or immediately for urgent matters. All information is treated as confidential and will not be released to outside organizations or individuals. Raising Special Kids conducts 100% follow-ups on all referrals to ensure each family’s needs have been met.
After I send the referral, what can a family expect?
- All Services and programs are provided to families at no charge
- Contact is made with the family within 24-48 hours after receiving the referral
- Confidentiality is valued. Information about the family is never released without their prior written permission
- Information and assistance is available in English and Spanish
- 100% Follow-up on Parent-to-Parent Support
Raising Special Kids is a 501 © (3) nonprofit organization. All programs and services are offered at no charge to families. For more information, call (602) 242-4366, or (800) 237-3007 toll free.
Family Referral Form
Please fax completed form to: 602-242-4306
Raising Special Kids provides support, information, resources, training and assistance to parents of children with disabilities or special health care needs in Arizona. All programs and services are offered free of charge in both English and Spanish, at all ages and stages of a child’s development.
By providing the following information, and a signature, parents are giving permission to initiate contact between Raising Special Kids and the family you are referring for services. Upon receiving your referral, the family will be contacted within 48 hours in most cases, or immediately for urgent matters. All information is treated as confidential and will not be released to outside organizations or individuals. Raising Special Kids conducts 100% follow-ups on all referrals.
Professional Information
Name (please print):_________________________________________
Agency / Org.:______________________________________________
Phone: ___________________________________________________
Email: ____________________________________________________
Signature: _________________________________________________
Family Information (please print)
Name: ____________________________________________________
Phone: ____________________________________________________
Address: __________________________________________City / Zip Code_______________
Email:________________________________________________
Child’s Name: ______________________________________Date of Birth:________________
Child’s Diagnosis/Special Needs: _______________________________________________
__________________________________________________________________________
Family Waiver / Release of Information
I hereby give permission to my care provider to release information to Raising Special Kids. I understand I can expect a phone call within a few days of this referral.
Signature of Parent/Guardian: __________________________________ Date: __________
5025 E. Washington St., Ste. 204, Phoenix, AZ 85034-2005
602-242-4366 Toll Free 800-237-3007 Fax 602-242-4306 www.raisingspecialkids.org
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En Español:
Forma de Referencia de la Familia
Por favor fax para Raising Special Kids en (602) 242-4306
Raising Special Kids provee apoyo, información, recursos, entrenamiento y asistencia, en el centro y norte de Arizona, a las familias de niños con discapacidad o necesidades de salud especiales. Todos los programas y servicios son provistos sin costo alguno en inglés y español a cualquier edad y etapa de desarrollo del niño.
Al proveer la siguiente información usted está dando autorización a Raising Special Kids para iniciar comunicación con las familias que usted esta remitiendo para servicios. En la mayoría de los casos, al recibir su remisión, la familia será contactada dentro de 48 horas o inmediatamente en casos emergentes. Toda información es tratada como confidencial y no será liberada a otras organizaciones o individuos. Raising Special Kids conduce seguimiento en todos los casos referidos para asegurarse que las necesidades de cada familia han sido satisfechas.
Información Profesional
Nombre (letra de molde por favor):_______________________________________________
Agencia/negocio: ______________________________número de teléfono:______________
Email:_____________________________________________________________________
Firma: _____________________________________________________________________
Información acerca de la familia (letra de molde por favor)
Nombre: ____________________________________ número de teléfono: ______________
Dirección: __________________________________________________________________
Ciudad Código postal
Email:______________________________________________________________________
Nombre del niño: ________________________________fecha de nacimiento: ___________
Diagnóstico/necesidad especial: _________________________________________________
___________________________________________________________________________
Autorización para liberación de información por parte de la familia
Por la presente doy autorización para liberar información a Raising Special Kids y entiendo que puedo esperar una llamada telefónica dentro de unos días después del recibir esta autorización.
Firma del padre o tutor: _______________________________________Fecha:___________
5025 E. Washington St., Ste. 204, Phoenix, AZ 85034-2005
602-242-4366 Toll Free 800-237-3007 Fax 602-242-4306 www.raisingspecialkids.org