Parent Mentor Program | Trusted Parents

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Thông tin được cung cấp sẽ được sử dụng bởi Mạng lưới hỗ trợ gia đình của NC và các bậc cha mẹ đáng tin cậy chỉ nhằm mục đích phù hợp với phụ huynh.

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Vui lòng dành chút thời gian để điền đầy đủ vào biểu mẫu.

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) Bắt buộc

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.

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