CarePortal Request

CASA volunteers can make CarePortal Requests for the children and families on their cases by submitting information to a staff member of CASA. The CASA staff member will then make the request to CarePortal on behalf of CASA. The information you submit on this form is all confidential information which is shared with a CASA of the Pikes Peak Region employee. No one outside CASA has access to this information.

Advocate Name*
Advocate Email*
Advocate Phone
Case Name/Number*
Names and Ages of Children Involved*
Are one or more of the children in out-of-home placement?*
- Yes
- No
How long has this case been open?*
What is the need you are submitting for?*
What is the approximate monetary value of the need?*
Requested Item Description*
Please tell us exactly what you hope to acquire through CarePortal. If you are requesting funding, tell us WHO to make a check out to. If requesting an item, please provide the link to purchase the item online. If you are requesting a gift card, tell us what store the gift card should be to.
Delivery Information
Once your request has been met, who should the item or funds be delivered to? Please provide the name and address of the person which should receive the item. If someone will pick the item up from the CASA office, please indicate in this field who will be the pick-up person.
What other resources have you or the team used in order to meet this need?*
Caseworker's Name*
Caseworker's Contact Information*
Are you OK with being contacted directly by the person who would like to fulfill this need?*
- Yes
- No
Case Details*
Please tell us a bit about the case while still maintaining confidentiality. Please be as descriptive as possible. (i.s. This case has a 3-year-old male and a 5-year-old female living with great aunt after severe abuse from their parents. Aunt could use some assistance helping with back-to-school clothes and backpacks.)
Name
This field is for validation purposes and should be left unchanged.

CarePortal Request

CarePortal Request

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