Date of Referral (required)

I have parental consent to share information with VELA (required)
YesNoN/A

Your Full Name (required)

Your Email (required)

Your Phone Number (required)

Referral Source (Agency/School/Clinic/Other) (required)

Your Position (required)

Parent or Caregiver's Full Name (required)

Parent or Caregiver's Phone Number (required)

Parent or Caregiver's Zip Code (required)

Parent or Caregiver's Primary Language (required)
EnglishSpanish

Child's Name (required)

Child's Age (required)

Child's Diagnosis (required)

VELA provides limited one-on-one Case Management for families that have an individualized need. To refer a family to Case Management, please check the primary reason for referral: Select All that Apply
Needs Case Management for Support with School with 504 Plan or IEPNeeds Case Management for Support Accessing Community Resources Relevant to DiagnosisNeeds Case Management for Support with Doctors and TherapiesNeeds Case Management for Support with Evaluations

Does this child have Medicaid? (This is not a requirement to receive services)
YesNoN/A

Child's Medicaid Number (This information is only used for Case Management)

Provide relevant family information related to need for referral.

How did you hear about VELA? (required)
Community FairFlyerNewsletterSocial mediaPresentationWebsiteWord of Mouth