Suzanne Tyner Autism Assistance Fund

Suzanne Tyner Autism Assistance Fund

-Application-
To apply for the Suzanne Tyner Autism Assistance Fund, you MUST live in one of the following counties in Northwest Ohio or Southeast Michigan.

Defiance County, Erie County, Fulton County, Hancock County, Henry County, Lucas County, Ottawa County, Paulding County, Putnam County, Sandusky County, Seneca County, Williams County, Wood County, Monroe County (Michigan), Lenawee County (Michigan)
How did you hear about us?*
Does your household have more than one individual diagnosed with autism?*

YesNo
If yes, please indicate the age of each individual diagnosed with autism.
Applicant Information
Applicant's Name*
Individual with autism
Applicant's Date of Birth*

MonthDayYear
Date
Guardian's Name (if applicable)
Relationship to Applicant
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Funding Request
Please enter below the category that best describes your request. Funding limits apply as follows:
- Autism Related Equipment and testing such as Sensory items, developmental supplies, assessments — up to $500
- Autism Related Services such as respite care, recreational therapy sessions, social skill courses, safety courses — up to $750
- Autism Related Programs such as ongoing educational and college programs, speech or occupational therapy— up to $1500
Maximum total assistance per applicant: $1500. Funds are disbursed directly to the provider, program, school, or vendor. Funds are not available as reimbursement or to pay for services previously rendered.
Program, Service, or Equipment Requested:*
Request Amount:*
Please enter the amount you are requesting, not to exceed the category limit or the $1500 maximum.
Total Cost:*
Please enter the full cost of the program, service, or equipment.
Insurance Information
Applicant's Insurance *
Copy of Insurance Card

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Additional Funding Support
Please provide any other support or funding that may contribute to the total cost of the program, service, or equipment requested in the box below. Examples include:
- Insurance coverage or reimbursement requests
- Applications submitted to community organizations such as the Project iAm Foundation (Acoustics for Autism) or Parker’s Purpose
- Support from your local County Board of Developmental Disabilities (Board of DD)
- Any other grants, scholarships, or financial assistance programs
If no additional funding has been requested or secured, please indicate “None.”
Please provide any other support of funding that may contribute to the total cost of Program, Service, Or Equipment Requested.*
Your Story
Please share your family’s story and provide details about the individual with autism. In your response, include:
- Age at diagnosis
- Current developmental needs or areas where support is needed
- The specific program, service, or equipment you are requesting
- How the assistance funds will positively impact the recipient’s development, safety, daily functioning, or overall well‑being
You are welcome to include any additional context, successes, challenges, or photos if you would like.
Your Story:*

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Photos:

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Required Documentation
Copy of signed autism diagnosis by M.D., D.O., or N.P.:*

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Previous Year Tax Return:*

**1040 Form is required, we will NOT accept a W2.
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Documentation showing cost of what you are requesting funding to support:*

**Previously rendered services not eligible.
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Authorization
Authorization:*

I hereby authorize Avenues to verify any/all information I have supplied in this application.
Name of person completing this form:*

First NameLast Name
Relationship to Applicant:*
Today's Date:*

MonthDayYear
Date
Release and Authorization for use of Image/Story
Avenue would like to use Suzanne Tyne Autism Fund recipient stories to show the Fund’s impact in our community. This includes, but is not limited to: social media, website, brochures, and fundraising activities.
I grant Avenues permission to use:*

Our pictureOur family story using first namesOur family story without any namesNone
Autism Counseling and Support Services Program
Autism Counseling and Support Services offers parent support, family coaching, and individual counseling. Our licensed therapists specialize in providing comprehensive support including advocacy, counseling, and skill-building for individuals of all ages and their families. Our services are covered by most insurance companies, including Medicaid.
Are you familiar with our Autism Counseling and Support Services Program?*

YesNo
Would you like to be contacted by a staff member to learn more about these services?*

YesNo
Should be Empty:

Suzanne Tyner Autism Assistance Fund

To apply for the Suzanne Tyner Autism Assistance Fund, you MUST live in one of the following counties in Northwest Ohio or Southeast Michigan.

Applicant Information

Funding Request

Insurance Information

Additional Funding Support

Your Story

Required Documentation

Authorization

Release and Authorization for use of Image/Story

Autism Counseling and Support Services Program