TLP Wishes : Application for Help

Information about Person Filling Out This Application

Last Name:

First Name:

TLP Name:

Street Address:

Address Line 2

Address Line 3

City:

State:

Zip Code:

Country:

Daytime Phone #

Evening Phone #

Email Address:

(if other)

Last Name:

Parent First Name:

TLP Message / Chat Board Name

Street Address:

Address Line 2

Address Line 3

City:

State:

Zip Code:

Country:

Daytime Phone #

Evening Phone #

Email Address:

Information about the RAD Family in Need

(Please provide as much personal information as possible)

Your Wish for this RAD Family (500 Words or Less)

Back to TLP WIshes

Does this child have a confirmed diagnosis of RAD?

Is this child currently working with an Attachment Therapist?

Therapist's Name:  

Therapist's Telephone Number:

I am a RAD Parent   I am a TeacherI am a Social WorkerI am a TherapistI am a PhysicianI am a Family MemberI am a FriendI am a TLP FriendOther

Yes  No   Unknown  

Yes  No   Unknown