Stone Soup Group Online Intake 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
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
Street Address
City
State
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
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
Professional
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...
Training
School Support/Special Education
Accessing Community Resources
Transition Resources
Behavioral Concerns
Rare/Genetic Diseases
Application Assistance
Guardianship
Medicaid/TEFRA
Medicaid Waiver
Other
I am interested in connecting with another family/parent and want to learn more about Stone Soup Group's MAP Mentor-Advocate-Partner Program.
Yes
No
"The MAP (Mentor, Advocate, Partner) Program is a parent mentoring program that trains experienced, seasoned parents of children with special needs and matches them with parents who are new to the road of disabilities or are experiencing a bump in the road. It gives parents someone to talk to and lean on emotionally during challenging times and possibly build long term friendships between parents with similar experiences."
Additional Information/Comments:
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