Intake Form Family | Milestones Autism Resources | Cleveland, OH

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

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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.

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

Gender

What is their race/ethnic background?

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