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We’re here to help, and to let you know that you’re not alone.
Please fill out the following form, so we can best assist you!

If you’re wanting to contact us by phone, or for other reasons, please use the Contact Us page.

 

Your Name - First and Last (required)

Street/Physical Address (required)

Mailing Address (if different than above)

City,  OREGON (we only serve Oregon residents),       Zip, (required)

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Your Email (required)

Area(s) of Interest
 Assistive Technology
 Brokerage/Support Services for Adults
 IEPs
 IFSP
 Childcare
 Employment
 Family Support
 Education
 Healthcare
 Housing
 Residential Services
 Respite Care
 Transitional Services
 Other
Other:

My role is;
 Individual with disability
 Family member
 Service provider
 Educator
 Other
Other role:

Ethnic / Race Identity (OPTIONAL)
 African American / Black
 American Indian / Alaskan Native
 Asian
 Caucasian / White
 Hawaiian / Pacific Islander
 Hispanic / Latino
 Russian / East European
 Multiracial
 Other

Additional information or questions you'd like to share

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