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Mind the Gap
Contact us Mind The Gap
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MIND THE GAP: Fill out this form to enroll or request More information about the program.
*
Indicates required field
Parent/Caregiver Name
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First
Last
Phone Number
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Email
*
Languages Spoken:
*
Zip Code
*
County
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Child's Name
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Child's Date of Birth
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Developmental Disability, if known
*
Who referred you to Mind the Gap, if known?
*
Please list the name of the person who referred you to Mind The Gap, if known
From the topics below what are you interested in learning more about?
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Condition/diagnosis specific Info. (Autism, ADHD, Down Syndrome, etc.)
Communication development
Navigating health systems
Behavior
Parents rights and child advocacy
Stigma
Healthy lifestyle/self care
Other (For example: translation services, transportation, and preparing your home for providers.)
All of the above
Select all that apply
How did you hear about Mind the Gap?
*
Warmline website
Warmline newsletter
Facebook/social media
Flyer
Regional center/Infant Development Program
Other local agency
Other - Please specify in comment box below
Comment
*
Pease use this space to ask any questions or tell us more about your child/family.
Submit
Mind the Gap
Formulario de Contacto
*
Indicates required field
Nombre
*
First
Last
Correo Electronico
*
Numero de Contacto
*
Idioma preferido
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Codigo Postal
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Nombre de Nino o Nina y Fecha de Nacimiento
*
Condado
*
Yolo County
Sacramento County
Su hijo/hija tiene discapacidad de desarollo?
*
Si
No
No estoy segura
Por Favor indique el diagnostico de su hijo/hija.
*
Que es lo que mas le interesa en aprender en el programa Mind the Gap?
*
informacion especifica sobre el diagnostico
desarrollo de la comunicacion
navegando por los sistemas de salud
comportamiento
derechos de los padres y abogacia
estigma de discapacidad
creando un estilo de vida saludable
Other
Como se entero de nuestro programa MTG?
*
WarmLine Family Resource Center
Boletin de WarmLine
Facebook/medios sociales
Volante
Centro Regional/Programa Infantil
Grupo de Apoyo
Comentarios Adicionales
*
Submit
