Parent Mentor Program | Trusted Parents

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Mpango wa Washauri wa Wazazi

Fomu ya Taarifa ya Mshauri wa Mzazi

Maelezo yaliyotolewa yatatumiwa na Mtandao wa Usaidizi wa Familia wa NC na Wazazi Wanaoaminika kwa madhumuni yaliyokusudiwa ya kulinganisha na mzazi pekee.

Fomu ya Habari

Tafadhali chukua muda kujaza fomu kabisa.

Which service are you interested in?

Request a Parent Mentor

Become a Parent Mentor

Parent's Full Name

What city do you reside in?

What county do you live in

Preferred Phone Number

Email Address

Preferred method of contact? (check all that apply) Required

Phone Call

Text

Best time to be contacted?

Primary language spoken

Occupation

If not parent, please provide name and telephone number of person fillout the form

Full name of child(ren)/individual with special healthcare needs

Age of child

List diagnosis or condition and age at the time child was diagnosis:

NICU?

Yes

If yes, for how long?

Gestational age at birth?

Tell us more about your child(ren) (i.e. educational needs, mobility, medical equipment, adaptive equipment, surgery, specialized living setting, behavior challenges, services, and therapies received, adopted, foster, etc.)

Please include any special concerns you may have for your child

If you have multiple children with special healthcare needs, please list name, age, gender, and diagnosis below:

I give permission for Family Support Network and Trusted Parents to release my name and number to another FSN program affiliated/parent for the sole purpose of making a successful match.

Mpango wa Washauri wa Wazazi

Fomu ya Taarifa ya Mshauri wa Mzazi

Fomu ya Habari

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