ECS Parents & Caregiver Resource Connection Intake

Fill out this detailed form so we can connect you with the most relevant services, programs, and resources for your family. All information is strictly confidential. Takes about 5–8 minutes.

Parent / Caregiver Information

Tell us about yourself so we can personalize your experience.

First Name *

Last Name *

Email Address *

Phone Number *

Best Time to Contact You

Preferred Language

Your Relationship to the Child *

Parent Grandparent Legal Guardian Foster Parent Sibling / Family Member Professional Caregiver Other

How Did You Hear About ECS?

Facebook Instagram TikTok YouTube Friend or Family Referral Google Search School or Teacher Doctor or Therapist Webinar / Event Other

Child / Dependent Information

Tell us about the child or children you care for.

💡 You only need to provide your child's first name and last initial for privacy protection.

Child's First Name *

Child's Last Initial

Child's Date of Birth *

Child's Current Age

Child's Gender Identity

Number of Children You're Seeking Help For

Diagnosis & Evaluation Information

Understanding your child's diagnosis helps us connect you to the right resources.

Has Your Child Received a Formal Diagnosis? *

Yes – Official Diagnosis Evaluation In Progress Suspected – Not Yet Evaluated No – Seeking Evaluation

Type of Diagnosis / Condition (Check All That Apply)

Autism Spectrum Disorder – Level 1 Autism Spectrum Disorder – Level 2 Autism Spectrum Disorder – Level 3 ADHD / ADD Intellectual Disability (ID) Global Developmental Delay Speech & Language Disorder Sensory Processing Disorder Anxiety Disorder OCD / Obsessive Compulsive Disorder Epilepsy / Seizure Disorder Down Syndrome Cerebral Palsy Learning Disability (Dyslexia, etc.) Mood / Behavioral Disorder Other / Multiple Diagnoses

How Old Was Your Child When Diagnosed?

Approximately When Was the Diagnosis Given?

Who Provided the Diagnosis? (Check All That Apply)

Pediatrician Psychologist / Neuropsychologist Psychiatrist Developmental Pediatrician Neurologist School Evaluation Team Early Intervention Program Not yet diagnosed

Primary Challenges Your Child Faces (Check All That Apply)

Communication / Speech Delays Meltdowns / Emotional Dysregulation Aggressive or Self-Injurious Behavior Sensory Sensitivities Social Skills / Making Friends Sleep Difficulties Feeding / Eating Challenges Toileting / Potty Training School Behavior / Academic Struggles Difficulty with Transitions / Routines Wandering / Elopement Mental Health / Co-occurring Conditions

Current Programs & Services

Let us know what services your child is currently receiving.

Is Your Child Currently Receiving Any Services? *

Yes, currently enrolled On a waitlist Services recently ended No – seeking services now

Current Services / Therapies Received (Check All That Apply)

ABA Therapy Speech & Language Therapy (SLP) Occupational Therapy (OT) Physical Therapy (PT) Early Intervention (Birth–3) Special Education / IEP Services Social Skills Groups Behavioral / Mental Health Therapy Feeding Therapy Respite Care Day Program / Day Habilitation Case Management / Coordination Family Counseling / Parent Support Medication Management / Psychiatry Music / Art / Play Therapy None at this time

Overall Satisfaction With Current Services

Gaps in Your Child's Current Care (Check All That Apply)

Not enough therapy hours per week Long waitlists for needed services No qualified providers in my area Need more parent training & coaching Lack of crisis / emergency support Transition planning (school → adult life) Services not coordinated with each other Providers lack cultural competence

Services & Support Needed

What does your family need most right now?

Services You Are Looking For (Check All That Apply) *

ABA Therapy Speech Therapy Occupational Therapy Physical Therapy Early Intervention Behavioral Support at Home Crisis Intervention / Safety Planning Respite Care Case Management / Coordination IEP / School Advocacy Social Skills Training Family Counseling / Therapy Financial Assistance / Benefits Help Supported Housing / Residential Info Transition / Vocational Services (18+) Parent Coaching & Training Online Parent Community ECS Online Courses

Biggest Barriers to Accessing Services (Check All That Apply)

Long waitlists Transportation / distance to providers Cost / out-of-pocket expenses Insurance denied or won't cover Difficulty finding qualified providers Language / cultural barriers Don't know where to start Work schedule / time constraints Child refuses services or therapy No major barriers at this time

How Urgent Is Your Need?

Insurance & Financial Coverage

This helps us connect you with programs your family qualifies for.

Does Your Child Have Health Insurance? *

Yes No – Uninsured Currently Applying

Type of Insurance (Check All That Apply)

Medicaid (Government / State) Medicaid Managed Care Plan CHIP (Children's Health Insurance) Medicare Private / Employer Insurance Marketplace / ACA Plan Tricare / Military Insurance No Insurance

Medicaid Waiver Programs — If Enrolled

Innovations Waiver (DD / NC) TBI Waiver CAP-DA Waiver CAP-C Waiver (Children) On waiver waitlist Not enrolled in any waiver Not sure – need help applying

Other Funding Sources (Check All That Apply)

Social Security (SSI / SSDI) State or Local Grants Nonprofit / Foundation Funding Paying fully out of pocket Crowdfunding / Community Support No additional funding

Is Financial Hardship a Factor in Accessing Services?

Yes – significant factor Somewhat No – finances are manageable Prefer not to say

Your Location

We use your location to connect you with local providers, events, and resources.

City *

County *

ZIP Code *

State *

How Long Have You Lived in This Area?

Are You Open to Virtual / Online Services? *

Yes – Both in-person and virtual Virtual / Online Only In-Person Only No Preference

Activities & Interests

Help us match your child and family to enrichment programs and activities.

What Activities Is Your Child Interested In? (Check All That Apply)

🏅 Sports & Athletics 🏈 Swimming 🎨 Art & Drawing 🎵 Music & Instruments 💃 Dance 💻 Technology & Computers 🍳 Cooking & Life Skills 🐾 Animals / Equine Therapy 🌿 Nature & Outdoors 📚 Reading & Storytelling 🎭 Drama & Theater 🤺 Yoga / Mindfulness 🔬 STEM / Science Projects 🤝 Social Groups / Peer Play 🎮 Video Games / Gaming Not sure yet

What ECS Support Are YOU Most Interested In? (Check All That Apply)

📚 ECS Calm in the Chaos Online Course 🎙 FREE ECS Crisis Management Webinar 👥 ECS Community Plus Group (FREE) 📱 ECS Member App Access 🎉 Live Events & Meetups 🤝 One-on-One Parent Coaching 📋 Local Resource Directory 📧 ECS Newsletter & Updates ✅ All of the Above!

Goals & Anything Else You'd Like to Share

This is your space. Tell us what matters most to your family right now.

What Is Your #1 Goal for Your Child Right Now?

What Has Been Your Biggest Challenge as a Caregiver?

Is There Anything Else You'd Like Us to Know?

How Would You Like ECS to Follow Up With You?

📧 Email 📞 Phone Call 💬 Text / SMS 📸 Facebook Messenger 📷 Instagram DM

🔒 Your Privacy Matters: All information is strictly confidential and used solely to connect your family with appropriate resources. ECS will never sell or share your personal information without your explicit consent.

By submitting this form you agree to our Privacy Policy and consent to be contacted by ECS.

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Your Family Deserves

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📋 Parents & Caregiver Resource Connection Intake Form

Get Connected to the Resources & SupportYour Family Deserves

Families Just Like Yours Are Finding Hope & Help

🌟 What ECS Offers Your Family

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Calm in the Chaos Course

ECS Community Plus Group

FREE Live Webinars

ECS Member App

📋 Parents & Caregiver Resource Connection Intake Form

Get Connected to the Resources & Support
Your Family Deserves