Referral/Intake Form

If you or someone you know needs any type of services, please complete the information in this form. Please complete as much information as possible about the family in need. 
If you are a service provider, please only list your information in the ‘additional information’ section. All other fields should be information about the family in need. 

Raleigh County Family Support Center will not deny services to families based on the information provided. Staff will work alongside families to identify which service will best serve the family. If there are any issues or you need any accommodations, please call/text (681) 539-0370 and/or email us at