Service Request

Thank you for your interest in RISE for Families! Please submit the following form to inquire about specific help that we can offer your family.

For general inquiries, please use the Contact Us form.

If you prefer a phone call instead of email, please include your contact number.
Information about the child for which you are requesting service, such as:
  • Name
  • Age
  • School district, school, and grade
If diagnosed, please indicate what diagnosis you have received. Also include information about any current services being utilized (whether in school or from outside clinics).
Describe any concerns you would like to address. Include desired services (ABA, speech therapy, school placement, etc) if known.
Insurance company and plan name (if known). Please DO NOT include account numbers.
Include any additional information you would like us to know.
1 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.