Trusted Parents

Request a Parent Match

If you would like to be matched with a Support Parents, please complete the form below.

We will act on your request as quickly as possible, however, please keep in mind that our Coordinators are parents themselves and most work on a part-time basis. Feel free to follow up on your request by emailing [email protected]. You may also call our Regional Office if you feel it is necessary.

We will protect all information provided, including names, addresses, phone numbers, birth dates, and medical information. For details see our Privacy Statement.

Family Information

In which county of North Carolina do you live?
Relationship to person with Special Needs
Full Name
Address
City
State
Zip
Phone
Best Time to Reach Me:
Email:
Domestic Status:
Ethnic Group:
Languages:
Full Name of Individual with Special Needs:
DOB: (mm/dd/yy)
Sex:
List disability or condition:
Please include any additional information about your child that might assist in making a good match, i.e., twins, disability the result of an accident, play/social skills, hobbies/interests, etc.
Please include any special issues or concerns you may have regarding your child:
I give my permission to release my name, phone number and/or email address to a trained support parent in order to complete this request for a parent match.
- Yes
- No
- Please contact me first.
Send Message