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.
What's your address?
What's your phone number?
What's your email address?
What's your child with special needs' name?
How old is your child with special needs?
Newborn - 5 years old
6 - 10 years old
11 - 16 years old
17 - 19 years old
What's your occupation and average annual salary?
What is your special needs child's diagnosis and when were they diagnosed?
What type of assistance are you needing?
Support and Advocacy
Guidance and Resources
What is your marital status?
Separated or Divorced
What other kinds of assistance have you received so far?
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