ASSIST Referral

ASSIST is a group facilitated by a Special Education Teacher designed for children aged 5-10, who are residents of Orange County and have OPWDD eligibility.

#1 Parent Name #1 Parent Name First Last
#2 Parent Name #2 Parent Name First Last
Child Name Child Name First Last
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Preferred Contact Method

Preferred Contact Method Text Email Phone Call
Has a Sibling with an OPWDD Certification

Has a Sibling with an OPWDD Certification Yes No
What Should we Know About Your Child?