Intake Form Family

Submit an Intake Form

Intake Form Family

Intake Form for Family Member / Friend

This form is to be completed by a parent, other family member or friend of an autistic individual to receive assistance.

Si el español es su idioma principal, puede traducir este formulario (y este sitio web) al español haciendo clic en la palabra Español en la esquina superior derecha de la ventana de este sitio web.

Person Completing Form First Name

Person Completing Form Last Name

I am looking for help for..First Name

I am looking for help for...Last Name

Phone Number

Phone Type

Address

Address 2

City

State

Zip

What county do you live in?

Email Address

Preferred Method of Contact

Would you like to communicate by texting?

Who do you need resources for?

What is your relation?

Are you their legal guardian?

How old are they?

Date of Birth

Gender

Do they prefer LGBTQ+ friendly resources?

What is their race/ethnicity?

What is the primary language of the autistic person?

What is the primary language spoken at home?

If other please give the language spoken.

Would you like to be connected with our Spanish helpdesk?

What are their diagnoses?

Where do they fall on the autism spectrum?

How does the individual communicate most frequently?

What insurance do they have?

Are you/they connected with their County Board of Developmental Disabilities?

Primary Reason for Request

Please provide a detailed description of your request:

How did you hear about Milestones? Please be specific. (Ex: Dr. Jones at Cleveland Clinic)

Submit

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