New Contact
As of May 2026, please expect a response within 4-6 weeks of contact. If you should like an update on your waiting list spot, please email atla@atlaak.org. ATLA will make three (3) attempts to get in touch. If we do not get a response after the third attempt, the case will be closed until we hear from the contact.
The following information should be for the person who would like ATLA services
Name (required)
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name of Parent or Guardian (required if individual being referred is under 18)
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Phone Number
Home
Cell (texting is okay)
Cell (texting is not okay)
Work
Email (required)
*
example@example.com
Address (required)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Area of Need (check all that apply)
Daily Living
Cognition
Communication
Environmental Adaptations
Hearing
Vision
Not Sure
Other
If you chose other, please describe below.
Alternative Contact Information
If there is someone else we should be in contact with regarding the person requesting ATLA services' case, please leave their information below.
Alternative Contact
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Client
Who should we contact first?
*
Main Contact
Alternative Contact
Please describe the individual’s needs or provide information that may be useful for ATLA specialists.
*
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