Unique Minds Intake Form
Unique Minds is a 501(c)(3) non-profit organization dedicated to assisting parents and families of children with special needs. If you are a parent with a special needs child, and looking for help of some kind, please complete this intake form and one of our representatives will follow up with you within 48-72 hours, or sooner. Please keep in mind, none of the answers to these questions will deter you from getting assistance.
What's your first and last name.
Your answer
What's your address?
Your answer
What's your phone number?
Your answer
What's your email address?
Your answer
What's your child with special needs' name?
Your answer
How old is your child with special needs?
What's your occupation and average annual salary?
Your answer
What is your special needs child's diagnosis and when were they diagnosed?
Your answer
What type of assistance are you needing?
What is your marital status?
What other kinds of assistance have you received so far?
Your answer
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