Individual Assistance Request
First Name
Last Name
Email
Phone Type
Mobile
Home
Work
Mobile Phone
May we text this mobile number?
Yes
No
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Home Phone
Work Phone
County
Please select...
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Out of state
N/A or Multiple Counties
Whole state (PA)
Primary Language
Please select...
English
Spanish
Other
Other language
Relationship to child
Please select...
Parent/Guardian
Grandparent
Professional
Child(ren) Information
Child's year of birth
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
Prefer not to answer
Race/ethnicity of the child(ren)
What can we help with?
IEP/Special Education
Early Intervention
Transition
Healthcare/Medical
Behavioral Health
Other
Other
Have you worked with PEAL Center before?
Yes
No
I'm not sure
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Contact Information