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1. Connect with a Family Support Specialist:

A Family Support Specialist is a staff member at ASK who is trained to help with health care and education issues related to disability. If you have specific questions about health or disability and need information, support, or advocacy, choose this option.

2. Request ASK to attend an exhibit fair or to provide a training:

Choose this option if you want ASK to attend an exhibit fair or if you would like us to provide training for your company, team, support group, conference, or other events.

3. Request a mentor or to become a mentor:

A mentor is a trained volunteer who has experience caring for an individual with a disability. Choose this option if you are looking for a listening ear who has “been there” and can offer support and encouragement. You may also use this link to become a mentor yourself.

All services provided to people with disabilities and their family members are FREE. Services to professionals are low to no cost.

Please choose from the following

Please complete the information below. All information submitted goes to a confidential database and will not be shared. We will contact you in the order that requests are received. It may take more time during times of high volume. You will receive an email once you submit your request.

What is your role?

Parent/ Guardian, Family Member

Self-Advocate

Professional

Contact Name (first and last):

We will make at least 3 attempts to contact you which could include phone, text or email. By providing your contact information you understand that we may use that information to reach you.

Contact Phone Number:

Contact Email Address or an alternate option such as a second phone number or mailing address:

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Submit the information below about the individual that you are contacting ASK about.

Individual's Name:

Individual's Month and Year of Birth:

Reason for Contact (select all that apply):

Health

Education

Community Resources

Other

Other:

Additional information about your reason for contact:

Please upload any documentation that you would like to share.

Please check this box if you DO NOT want to receive our monthly E-Newsletter

Your Name (first and last):

We will make at least 3 attempts to contact you which could include phone, text or email. By providing your contact information you understand that we may use that information to reach you.

Your Phone Number:

Your Email Address or an alternate option such as a second phone number or mailing address:

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Your Month and Year of Birth:

Reason for Contact (select all that apply):

Health

Education

Community Resources

Other

Other:

Additional information about your reason for contact:

Please upload any documentation that you would like to share.

Please check this box if you DO NOT want to receive our monthly E-Newsletter

Professionals can use this section of the form to ask a Family Support Specialist for assistance or to refer a family or individual to ASK. If you choose for ASK to contact the family or individual directly, we will not be able to disclose any information without a signed release.

Professional Name (first and last):

Job title:

Doctor/ Nurse

Therapist/ Counselor

Social Worker/ Case Manager

Service Provider

School Professional

Legal Professional

Other

Other:

Organization Name:

We will make at least 3 attempts to contact you which could include phone, text or email. By providing your contact information you understand that we may use that information to reach you.

Professional Phone Number:

Professional Email Address:

Who would you like us to contact?

Yes, I have notified the family/ individual that their information has been submitted to ASK Resource Center and that ASK may use this information to contact them:

Upload a SIGNED Release of Information

Parent/Individual with Disability Contact Name (first and last):

Submit the information below about the family/ individual that you are contacting ASK about.

Parent/Individual with Disability Contact Phone Number:

Parent/Individual with Disability Contact Email Address (if you cannot provide an email address please provide a second way to reach the family/individual):

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Individual's Name:

Individual's Month and Year of Birth:

Reason for Contact (select all that apply):

Health

Education

Community Resources

Other

Other:

Additional information about your reason for contact:

Please upload any documentation that you would like to share.

Please check this box if you DO NOT want to receive our monthly E-Newsletter

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Reason for Contact (select all that apply):

Health

Education

Community Resources

Other

Additional information about your reason for contact:

Please upload any documentation that you would like to share.

Please check this box if you DO NOT want to receive our monthly E-Newsletter

Request (select all that apply):

Training

Resource/Exhibit Fair

Contact Name:

Organization:

By providing your contact information you understand that we may use that information to reach you.

Contact Email Address:

Contact Phone:

Preferred method of contact (select all that apply):

Email

Phone

Event Name:

Event Date and time:

Event Address/ Location:

Other Event Details:

Please upload any documentation that you would like to share.

Please check this box if you DO NOT want to receive our monthly E-Newsletter

What is your mentoring request?

Contact Name (first and last):

We will make at least 3 attempts to contact you which could include phone, text or email. By providing your contact information you understand that we may use that information to reach you.

Contact Phone Number:

Contact Email Address or an alternate option such as a second phone number or mailing address:

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Additional information about your reason for contact:

Please check this box if you DO NOT want to receive our monthly E-Newsletter

Become an ASK Each Other Mentor

ASK Each Other Mentors share lived experiences about disability with others. Mentors share stories, answer questions, provide unbiased information, share community connections and give emotional support. Free training is provided along with opportunities to connect and learn with other mentors.

Who can become a Mentor?
1. a Parent, Guardian/Caretaker, or Sibling of a person with a disability or special health care need
OR
2. an Individual with a Disability or special health care need

Steps to become a Mentor

A Family Support Specialist will contact you by phone or email to discuss completing the following:
1. Conflict of Interest form
2. Mentor Information form
3. ASK Each Other Mentor Training
4. Background Check

For questions or to become a mentor, complete the information below.

Contact Name (first and last):

City that you live in:

We will make at least 3 attempts to contact you which could include phone, text or email. By providing your contact information you understand that we may use that information to reach you.

Contact Phone Number:

Contact Email Address or an alternate option such as a second phone number or mailing address:

Our Family Support staff will call you to discuss details of your intake.

Preferred time to be reached between 8AM-4PM (If you need a call back outside of our business hours we can schedule a time with you.):

Do you need an accommodation to access our services?

Why do you want to be a Mentor? (Briefly describe any special skills or experiences):

Please check this box if you DO NOT want to receive our monthly E-Newsletter

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