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Intake Form for Individual with ASD

This form is to be completed by individuals who are on the autism spectrum or who suspect they are on the spectrum in order to receive assistance for themselves. If you are a parent or other family member of an individual with autism, please use this form.

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

Age

Date of Birth

Gender

What is your race/ethnic background?

What are your diagnoses?

Where do you fall on the spectrum?

What insurance do you 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.

Submit

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