Parent to Parent Registration Form  

Are you a professional?  Please click here. 

Parents: If you would like a 1-1 match with another parent around a specific diagnosis or other issue, please use the space below to detail your request.

If you are looking for information about school districts, resources in Colorado, Medicaid/insurance, respite, etc., we invite you to sign-up for the P2P-CO listserv and ask your question online.  Our very knowledgeable staff and parent listserv members can answer most of your questions or direct you to the appropriate resource.

If you do not have Internet access at home or work, please feel free to call us at 877-472-7201.

***The only information required to be on

the P2P database are the starred items***

(Additional information you provide helps us to make better connections between parents. We also compile demographic information for our funders, with no parent information attached to the data.) You may call 1-877-472-7201 to sign up for membership over the phone or you may fill in this form.

Parent Information

*First Name
*Last Name
*Address
*City
*Zip
Colorado County
*Home Phone
Cell/Work Phone
*Email  address

(required if you are interested in joining P2P listservs)

Relationship Status

How did you hear about us?

LISTSERVS:

NOTE: If you are requesting to be a part of our email discussion groups, you must provide your email address above.

 

Check the email information/discussion group(s) you are interested in:

P2P-CO (Parent to Parent Listserv)

P2P-Policy (Policy Listserv)

P2P-CO-Hispano (Spanish Listserv)

 

INSURANCE INFORMATION:

Private Insurance No Insurance

Medicaid Waiver Medicaid Fee for Service

Type/name of Medicaid Waiver, if applicable

 

TRAINING COMPLETED:    
Parents Encouraging Parents (PEP) PEAK Training
Training for Transition (T4T) Policy/Legislative Training
Mobilizing Families

Other training:
   
INVOLVEMENT/EXPERIENCE:  
Local Gov't School Committees
SSI IDEA
Advisory Boards Other involvement:
Disability and/or family support organizations you are connected with:

Information on son/daughter with diagnosis

If you have more than one child with a diagnosis, you only need to fill out this part of the form for each additional child, including parent name above.
*Name
*Date of Birth
Sex Male Female

*Diagnosis/Disability

EXPERIENCE: My son/daughter's disability/special health care need has given me experiences related to the following:

Speech

Vision 

Hearing

Mobility

Behavior

Toileting

Feeding

Diet

Personal Attendant Services

Transportation

Employment

Housing Options
Other # of medications administered

 

Hospitalizations/surgery/medical procedures related to disability:

THERAPIES:

Occupational (OT) 

Physical (PT)

Speech

Behavior 

Cognitive

Play

Psychotherapy

Sensory Integration (SI)

Nutritional

Water

Hippotherapy (Horse)

Hyperbaric Oxygen (HBOT)
Other

Special equipment and/or treatments related to disability:

FAMILY INFORMATION:

Number of children in family:
Your son/daughter is:
Primary language spoken in home:   English  Spanish     Other
Ethnicity/Culture (check all that apply)  
Caucasian African American
Latino  Asian
Native American Other

 

CHILD INFORMATION:

Lives at    Other

For son/daughter ages 3-18:

School Program

School District enrolled in

For son/daughter over age 18 (check all that apply):

Transition program

College

Full-time employment

Part-time employment

Not employed

Adult services

Other

**(Must be checked) Parent to Parent has my permission to release only my name, phone number, email address to another parent on our database.

Yes No