Family&Friend Intake Form

Are you seeking resources for yourself or for someone else?

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.Format: (000) 000-0000.

What is your relationship to the person you're seeking resources for?

Are you their legal guardian?

Would you like to be connected with our Spanish Helpdesk?

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?

Please provide a detailed description of your request

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Name

First NameLast Name

How old are you/they?

What is your/their Date of Birth?

Date

What is your/their Gender?

What is your/their self-identified gender?

What is your/their sexual orientation?

Do you/they prefer LGBTQ+ resources?

What is your/their race/ethnicity?

Where do you/they fall on the autism spectrum?

What are your/their diagnoses?

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What insurance do you/they have, if any?

Do you/they receive any of these resources: Medicaid, SNAP, TANF, SSI or similar?

What is your/their primary language?

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?

What is the primary language spoken at your/their home (not listed above)?

How do you/they communicate most frequently?

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

If your child is school aged, are they enrolled at :

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

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