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Get in touch

Have a question?
Want a Family Support Specialist to contact you?
Have feedback? Let us know! We are always striving to do our best for Arizona families.

Please fill out the form below

Phone: 602-242-4366 or 800-237-3007
Email: info@raisingspecialkids.org

Family Referral Form

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Please select one of the following:

Professional Information

Your First Name

Your Last Name

I am a:

Agency

Phone

Family Information

Parent/Caregiver's First Name

Parent/Caregiver's Last Name

Chosen Pronouns

Other Pronouns

Primary Language

Preferred Method of Contact

Phone

City

County

Child's First Name

Child's Last Name

Date of Birth

Chosen Pronouns

Other Pronouns

Child's Diagnoses:

Needs Information About

Additional Information

Optional Information

This information helps us ensure that we are serving our entire community. This section is optional and has no impact on the availability of services from Encircle Families. Our services are always available at no cost to all Arizona families.

Race

Ethnicity

Do You Receive Public Assistance

Examples include free school lunches, Income-based AHCCCS, SNAP.

# of Household Members

Household Income

Contact Information

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Family Referral Form

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For Professionals

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Staff & Board Access

Americans with Disabilities Act (ADA)

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Offices