Family&Friend Intake Form

Are you seeking resources for yourself or for someone else?*

I am a family member or friend and need resources to help themI am a professional and need resources to help a clientI am an adult seeking resources about diagnosisI am an autistic individual and need resources for myself
Your Information

Please fill in the information below about yourself.
Name*

First NameLast Name
Employer/Agency*
Title*
Primary Address Type
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Type a question
Preferred Communication Method
Preferred Email
Email Address
example@example.com
Preferred Phone
Phone Number
Please enter a valid phone number.
What is your relationship to the person you're seeking resources for?
Are you their legal guardian?

YesNo
Would you like to be connected with our Spanish Helpdesk?

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

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What topics are you seeking resources about?

ASD AssessmentNew DiagnosisIEP/SchoolTutor/AideRespite/DaycareBehaviorMedicalSoc & Rec/CampEmploymentResidentalHigher Ed/Trade/Vocational SchoolLife SkillsTransition to AdulthoodGov't Benefits/WaiversLegalSupport GroupsTherapyFunding - Scholarships/GrantsRelocating
Please provide a detailed description of your request

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Autistic Person's Information

Please provide the following information about the autistic individual you wish to assist.
Name

First NameLast Name
How old are you/they?*
What is your/their Date of Birth?

MonthDayYear
Date
What is your/their Gender?

MaleFemaleNon-binarySelf Identify
What is your/their self-identified gender?
What is your/their sexual orientation?

Straight/HeterosexualLGBTQ+I prefer not to answer
Do you/they prefer LGBTQ+ resources?

YesNo
What is your/their race/ethnicity?
Where do you/they fall on the autism spectrum?

Not on the spectrumASD suspectedMildModerateSevereI don't know
What are your/their diagnoses?

0/255
What insurance do you/they have, if any?
Do you/they receive any of these resources: Medicaid, SNAP, TANF, SSI or similar?

YesNoI don't knowI prefer not to answer
What is your/their primary language?

EnglishSpanishSwahiliArabicNepaliAmerican Sign Language (ASL)Other
What is your/their primary language (not listed above)?
Do they live in your household?*
What is the primary language spoken at your/their home?

EnglishSpanishSwahiliArabicNepaliAmerican Sign Language (ASL)Other
What is the primary language spoken at your/their home (not listed above)?
How do you/they communicate most frequently?

VerballyNon-verbal communicationCommunication deviceEcholaliaI don't know
Are you/they connected with their County Board of Developmental Disabilities?

YesNoI don't know
If your child is school aged, are they enrolled at :

A Public SchoolA Private SchoolHomeschooledNot enrolledOther
DISCLAIMER: Please note that by clicking submit you are agreeing to receive occasional correspondence from Milestones Autism Resources. The personal information collected is only used by Milestones Autism Resources staff. We do not share your information with any third parties. We use your personal information to appropriately process your requests and present you with the information you need, and we may use your demographic information for grant applications.

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. AVISO DE RESPONSABILIDAD: Tenga en cuenta que al hacer clic en Enviar, acepta recibir correspondencia ocasional de Milestones Autism Resources. La información personal recopilada solo la utiliza el personal de Milestones Autism Resources. No compartimos su información con terceros. Usamos su información personal para procesar adecuadamente sus solicitudes y presentarle la información que necesita, así como también podríamos usar su información demográfica de las solicitudes de subvenciones.
I consent to the disclaimer listed above*

Yes, I consent. / Sí, doy mi consentimiento.No, I don't consent. / No, no doy mi consentimiento.
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Your Information

Autistic Person's Information