Stone Soup Group Online Intake Form
This form is for individuals requesting support for themselves, their children, their families, or friends. This form is not for professionals referring a family. If you are a professional who wants to refer a family, please use our Referral Form.
Click here to access the Referral Form.
I am contacting you about:
my child, family member or person with disability
myself
Your Information
First Name
Last Name
Mobile Phone
Would you like to receive text messages?
Yes
No
select "Yes" to receive SSG updates, newsletters, event notifications and promotional information via text message
x
Email
Would you like to be added to our mailing list?
Yes
No
select "Yes" to receive SSG updates, newsletters, event notifications and promotional information via email
x
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Borough/Region
Please select...
Aleutians East
Aleutians West
Anchorage
Bethel
Bristol Bay
Denali
Dillingham
Fairbanks North Star
Haines
Juneau
Kenai Peninsula
Ketchikan Gateway
Kodiak Island
Lake And Peninsula
Matanuska Susitna
Nome
North Slope
Northwest Arctic
Petersburg
Prince Wales Ketchikan
Sitka
Skagway Hoonah Angoon
Southeast Fairbanks
Valdez Cordova
Wade Hampton
Wrangell Petersburg
Yakutat
Yukon Koyukuk
Out of State
Your Birthdate
Preferred Language
Please select...
English
Spanish
Samoan
Hmong
Yupik
Russian
Tagalog
Teluge
Korean
Gambian
Chinese
Mandarin
ASL
Other
Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Pacific Islander
Some Other Race
White
Prefer not to disclose
What insurance do you have?
Medicaid/TEFRA/Denali KidCare
Medicare
Tricare
Private
Other
Uninsured
Are you and/or your family affiliated with the military?
Yes, active military
Yes, reserve & guard
Yes, veteran/retired
No military affiliation
Which branch of the military?
Army
Air Force
Coast Guard
Marines
Navy
Are you in contact with your EFMP (Exceptional Family Member Program)?
Yes
No
Disability
(select all that apply)
ADD/ADHD
Autism
Behavioral/Mental Health
Cerebral Palsy
Cleft Lip/Palate
Cognitive Impairment
Developmental Disability
Emotional Disability
Epilepsy
Hearing Impairment
Learning Disability
Neurological
Orthopedic
Physical Disability
Rare/Genetic Disease
Speech/Language
Traumatic Brain Injury
Vision Impairment
Other/Unknown/Suspected
Child/Family Member/Person with Disability Information
Relationship to Child/Person
Please select...
Guardian
Parent
Foster Parent
Grandparent
Aunt/Uncle
Sibling
Cousin
Partner/Spouse
Other Relative
Friend
Is Child/Family Member/Person their own guardian? [for ages 18+]
Yes
No
I don't know
First Name of Child/Family Member/Person
Last Name of Child/Family Member/Person
Birthdate of Child/Family Member/Person
Gender of Child/Family Member/Person
Male
Female
Non-binary
Other
Race/Ethnicity of Child/Family Member/Person
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Pacific Islander
Some Other Race
White
Undisclosed
Unknown
What insurance does the Child/Family Member/Person have
?
Medicaid/TEFRA/Denali KidCare
Medicare
Tricare
Private
Other
Uninsured
Child/Family Member/Person Disability (select all that apply)
ADD/ADHD
Autism
Behavioral/Mental Health
Cerebral Palsy
Cleft Lip/Palate
Cognitive Impairment
Developmental Disability
Emotional Disability
Epilepsy
Hearing Impairment
Learning Disability
Neurological
Orthopedic
Physical Disability
Rare/Genetic Disease
Speech/Language
Traumatic Brain Injury
Vision Impairment
Other/Unknown/Suspected
Specifically, I would like more information or support on...
Parent Resources, Support and/or Training
School Related Support
Healthcare Information and Assistance
DDRC/Medicaid Waiver
*Please select the highest area of need at this time. When you have met with a Navigator they will help with any other concerns you have.
MAP (Mentor, Advocate, Partner) Program and Compass Group
The MAP Program offers parent mentoring that can provide an emotional shoulder to those caring for a child with special needs. The Compass Group is a non-therapeutic support group that meets monthly as part of the MAP program and is available for participating parents.
I am interested in learning more about the MAP Program and Compass Group:
Yes
No
The Program Coordinator will contact you via email regarding the program.
Additional Information/Comments:
*Please allow up to 3-5 business days for your online intake request to be processed
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information