Open Enrollment

Enroll Your Family

Complete the form below and a member of our team will follow up with next steps. All information is kept confidential.

Contact Information

Full Name *

Email Address *

Phone Number

Preferred Contact Method

Address / City / County

Best Time to Contact

Family Information

Who is part of the family?

Number of Children Involved

Ages of Children

What type of family support are you seeking?

Are both households / parents willing to participate?

Are there any safety concerns we should know about?

Court / Referral Information

Is there currently an open court case?

If yes, what county is the case in?

Type of case

How were you referred?

Do you have any upcoming court dates?

Briefly describe what support your family is hoping to receive

Required: I understand that The Patchwork Agency provides education, family support, referrals, and case management services, but does not provide legal representation or emergency services.