Parent/Guardian Name(s) * First Name Last Name Child's Name * Name of child(ren) with a disability or complex medical need First Name Last Name Email * City * Zip Code * What brings you to RESTkc? * Acute crisis Ongoing support Burnout Other How did you hear about RESTkc? * Referral Social media Friend Provider Other I consent to being contacted by RESTkc in response to this form submission. * Yes No Thank you for completing our family intake form! You should now be redirected to our eligibility survey, which will help us determine how best to serve you.
