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, "Family Waiver/Release of Information"
FamilyWaiver.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 central and northern 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.

I, ____________________________________am referring the following family to Raising Special Kids for support and services for their Child:

Signature:____________________________________________

Printed Name_________________________________________

Agency / Org.:________________________________________

Phone:_______________________

Family Information (please print)

Name:_______________________________________________

Phone:_______________________________________________

Address:_____________________________________________

City / Zip Code________________________________________

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 receipt of this referral.

Signature of Parent/Guardian:__________________________________

Date:___________________________________

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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.