CONTACT US

How can we help?  Please complete the form below and we will attempt contact you by the next business day.  

NOTE:  This form is for intended individuals and families in need.  If you are a professional referring someone to us, please click HERE

Your Name *
Your Name
Phone Number
Phone Number
In your own words, please tell us about your situation.
Tell us more about the person in need of assistance
Child's Name *
Child's Name
Date of Birth
Date of Birth
Gender
Race
Ethnicity
ESE?
(Exceptional Student Education)
Psychiatrist and/or Therapist Phone Number
Psychiatrist and/or Therapist Phone Number
Address
Address
Other Agencies Currently Involved
BY CLICKING SUBMIT, I GIVE PERMISSION TO SUCCESS 4 KIDS & FAMILIES AND ITS REPRESENTATIVES TO CONTACT THE PARENT/CAREGIVER OF THE CHILD AS ENTERED IN THIS FORM IN CONNECTION WITH MY DESIRE TO SEEK SERVICES WITH THE AGENCY. I ACKNOWLEDGE THAT I AM THE PARENT/ GUARDIAN/ OR CAREGIVER TO THE CHILD DESCRIBED IN THIS FORM, AND/OR THAT I HAVE SPOKEN WITH AND RECEIVED PERMISSION FROM THE CAREGIVER TO SUBMIT THIS APPLICATION ON THEIR BEHALF.