CONTACT US Phone: (860) 625-6656Email: PositiveAdversity@gmail.com REFERRAL FORM Name of individual that needs care: * First Name Last Name Phone Number * Person filling out this form Email * What city are they located in? * How old is the individual? Preferred Language You can leave blank if you prefer English! Does the person receiving care have any medical conditions or difficulties? What kind of help were you interested in? It's ok if you're not sure yet. We can help as we learn more. Are there any smokers or pets in the home? Tell us more about your situation: Thank you!
