Contact Us

request for Family Support, Training OR Mentoring

Use the form below to request:
1) contact with a Family Support Specialist,
2) request training or attendance at a resource/exhibit fair,
3) or request to match with or become a mentor.

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 up to 7 business days 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):

Contact Phone Number:

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

Preferred method for initial contact:

Preferred time to be reached if by phone (We will attempt to use times given):

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.

Your Name (first and last):

Your Phone Number:

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

Preferred method for initial contact:

Preferred time to be reached if by phone (We will attempt to use times given):

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.

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:

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:

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):

Preferred method for initial contact:

Preferred time to be reached if by phone (We will attempt to use times given):

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.

Preferred method for initial contact:

Preferred time to be reached if by phone (We will attempt to use times given):

Do you need an accommodation to access our services?

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.

Request (select all that apply):

Training

Resource/Exhibit Fair

Contact Name:

Organization:

Contact Email Address:

Contact Phone:

Preferred method of contact (select all that apply):

Email

Phone

Event Name:

Event Date:

Event Address/ Location:

Other Event Details:

Please upload any documentation that you would like to share.

What is your mentoring request?

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:

Contact Phone Number:

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

Preferred way to be contacted:

Preferred time to be reached if by phone (We will attempt to use times given):

Do you need an accommodation to access our services?

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