Intake Form Family | Milestones Autism Resources | Cleveland, OH

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Milestones Annual Benefit 2019 - October 26, 2019
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Milestones Autism Resources

4853 Galaxy Parkway, Suite A
Warrensville Heights, OH 44128

Phone: (216) 464-7600

For Families

For Professionals

For Individuals

For The Community

Welcome To Milestones

Milestones Autism Resources improves the lives of individuals on the autism spectrum by educating, coaching and connecting the autism community with evidence-based information.

About Milestones

Need Assistance? Let Milestones Be Your Local Guide.

Our team is here for you with a background in behavioral intervention. social work, and special education. Learn how we can help you today.

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We feature more than 1,000 educational, therapeutic, medical, and recreational resources, with a special focus on resources in Ohio.

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Milestones Autism Conference

National Autism Conference Learn about our annual conference that provides cutting-edge autism strategies and support to professionals, parents and individuals on the spectrum.

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Your generosity helps families impacted by autism at every age and ability.

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Volunteering makes a difference for each person with autism to fulfill their unique potential.

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HelpdeskNeed assistance? Let Milestones be your local guide.

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Home Services Submit an Intake Form Intake Form Family

Submit an Intake Form

Intake Form Family

Intake Form for Family Member / Friend

This form is to be completed by a family member or friend of an individual with autism to receive assistance.

Due to our Conference, please allow 10 days for a response from our Helpdesk staff. Thank you.

Your First Name

Your Last Name

Phone Number

Phone Type

Alternate Phone Number

Alternate Phone Type

Address

Address 2

City

State

Zip

Email Address

Can we say Milestones Autism Resources when calling? If not, how can we identify ourselves?

Preferred Method of Contact

Who are you reaching out on behalf of?

What is your relation? Are you their legal guardian?

What is their name?

Age

Date of Birth

Sex

What is their race/ethnic background? (Optional)

What are their diagnoses?

Where do they fall on the autism spectrum?

Are they verbal?

What insurance do they have?

Please provide a detailed description of your request:

Please let us know the level of support you need.

How did you hear about Milestones? Please be specific.

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Need assistance? Let Milestones be your local guide.

Unsure of where to start? Call our free Helpdesk with your questions, and we will do the research for you!

Call: (216) 464-7600 x200