Refer a family Family Referral Form Choose a language to translate this form. Please select one of the following:Please select... I am referring a family that is aware that I am making this referral. I am referring myself as a parent/family member. Professional Information Your First Name Your Last Name I am a:Please select... DDD Staff AzEIP Staff AZ Newborn Screening Staff Behavioral Health Professional Medical Professional Education Professional Other Professional Agency Email Phone Family Information Parent/Caregiver's First Name Parent/Caregiver's Last Name Chosen PronounsPlease select... She/Her He/Him They/Them She/They He/They Other Other Pronouns Primary LanguagePlease select... English Spanish Other Preferred Method of ContactPlease select... Phone Text Email Phone Email CityPlease select... Anthem Apache Junction Arizona City Avondale Avra Valley Benson Bisbee Buckeye Bullhead City Camp Verde Casa Grande Casas Adobes Catalina Catalina Foothills Cave Creek Chandler Chinle Chino Valley Citrus Park Colorado City Coolidge Corona de Tucson Cottonwood city Doney Park Douglas Drexel Heights Eagar El Mirage Eloy Flagstaff Florence Flowing Wells Fort Mohave Fortuna Foothills Fountain Hills Gilbert Glendale Globe Gold Canyon Golden Valley Goodyear Green Valley Guadalupe Holbrook Kayenta Kingman Lake Havasu City Litchfield Park Marana Maricopa Mesa New Kingman-Butler New River Nogales Oro Valley Page Paradise Valley Paulden Payson Peoria Phoenix Picture Rocks Prescott Prescott Valley Queen Creek Rincon Valley Rio Rico Saddlebrooke Safford Sahuarita San Luis San Tan Valley Scottsdale Sedona Show Low Sierra Vista Sierra Vista Southeast Snowflake Somerton South Tucson Sun City Sun City West Sun Lakes Surprise Tanque Verde Tempe Thatcher Tolleson Tuba City Tucson Tucson Estates Vail Valencia West Verde Village Wickenburg Williamson Winslow Youngtown Yuma Other CountyPlease select... Maricopa Apache Cochise Coconino Gila Graham Greenlee La Paz Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Child's First Name Child's Last Name Date of Birth Chosen PronounsPlease select... She/Her He/Him They/Them She/They He/They Other Other Pronouns Child's Diagnoses: Needs Information AboutPlease select... General Raising Special Kids Information Behavior Early Childhood/Early Intervention Denial of Services Guardianship/Legal Options at Age 18 New Diagnosis NICU Special Education - Evaluation/Eligibility Special Education - IEP Special Education - Placement Special Education - Dispute Resolution Transition to Adulthood 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. RacePlease select... Asian Black or African American Native American/American Indian or Alaskan Native Native Hawaiian or Pacific Islander White Other EthnicityPlease select... Non-Hispanic or Non-Latino Hispanic or Latino Unknown Do You Receive Public Assistance Please select... Yes NoExamples include free school lunches, Income-based AHCCCS, SNAP. # of Household MembersPlease select... 2 3 4 5 6 7 8+ Household IncomePlease select... $22,600 or less $22,601 - $37,700 $37,701 - $60,300 $60,301+ $25,450 or less $25,451 - $42,400 $42,401 - $67,850 $67,851+ $28,250 or less $28,251 - $47,100 $47,101 - $75,350 $75,351+ $30,550 or less $30,551 - $50,900 $50,901 - $81,400 $81,401+ $32,800 or less $32,801 - $54,650 $54,651 - $87,450 $87,451+ $35,050 or less $35,051 - $58,450 $58,451 - $93,450 $93,451+ $37,300 or less $37,301 - $62,200 $62,201 - $99,500 $99,501+ reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
