Services Request

Home / Services Request

Download the PIA Family Profile Sheet or complete it online below.

Family Profile Sheet

If you are human, leave this field blank.

Family Name

Mothers Information

Mother's Name

Home Phone

Cell Phone

Work Phone

Email Address

Occupation

Company Name

Father's Information

Home Phone

Cell Phone

Work Phone

Email Address

Occupation

Company Name

Non Affected Siblings

Sibling 1

Age

Sibling 2

Age

Sibling 3

Age

Other Extended Family Involved

Siblings willing to speak to the media:

Child Affected by Autism Spectrum Disorder

Name

Age

Age Diagnosed

Diagnosis (Where on the Spectrum):

What were the signs that lead you to believe that your child had a developmental disorder?

How your child communicates (i.e. verbal, sign language):

Types of therapy your child receives:

Please include name of therapy and the days per week the child attends.

What treatment/therapy have you found most affective?

Primary care provider to affected child:

Phone:

E-mail:

Other extended family involved (i.e. Grandparents):

Approximate yearly cost (i.e. medical attention/care giving):

Do you have Medicaid Waiver?

Yes

If not, are you on the Waitlist?

Yes

Does health insurance cover any therapies?

What is your child’s story?

How has Autism affected your other children?

If you could speak to the media regarding your family’s situation with Autism Spectrum Disorder, what topic would you focus on?