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Thank you for your interest in the Rainbow Kidz program.
Please use the form below to connect with us and let us know more about your needs.

Once you complete this form, one of our counselors will be in touch with you
to discuss the services that we can provide.

Referrer Information

*Required Information

Child(ren) Information

*Required Information
 School Grief Support Group
 Camp Rainbow
 Individual Counseling Session

Parent/Legal Guardian Information

*Required Information