Request for Orientation to Autism Kit

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in the Orientation to Autism Kit! When your child is first diagnosed, it can be an overwhelming time. Sometimes you're given very little information other than the diagnosis, and it can be hard to know where to start. Other times you may be given so much information, that it's hard to know which route to go. We hope this kit can get you started. It should be noted that we have a limited number of kits at this time. We will produce additional kits based on funding. If you were to request a kit after all had been distributed, you will be informed and placed on the request list for the next round of kits.

Email *

Due to funding limitations, these kits are only available for those who reside within our service region of North Louisiana. Which region do you live in? *

Region 1: Caddo Parish

Region 2: Bossier, De Soto, Red River Parishes

Region 3: Webster, Claiborne, Bienville Parishes

Region 4: Union and Morehouse Parishes

Region 5: Lincoln, Jackson, Winn Parishes

Region 6: Ouachita Parish

Region 7: Caldwell, Richland, Franklin Parishes

Region 8: East Carroll, West Carroll, Madison, and Tensas Parishes

What is your full name? *

What is your mailing address? (Be sure to include city and zip code. We will be shipping you the box) *

What is your relationship to the child? *

The following questions are meant to collect information regarding ages served by this initiative, as well as additional information, as a means for us to improve our services and support other initiatives. While this information is very helpful, it is voluntary for you to provide it.

Yes, I understand the following information is voluntary

Clear selection

How old is your child?

At what age was your child diagnosed?

Does your child receive private therapy services? (not school based services) Please check all that apply.

No private therapy services

ABA therapy

Speech Therapy

Occupational Therapy

Physical Therapy

Other:

Does your child receive any other services?

Early Steps-Individualized Family Service Plan

Services Plan (for children who meet criteria for school-based services, but are not in the public school system)

IEP

504 Plan

No additional services

Where was your child evaluated for Autism?

Once diagnosed, did the evaluation team provide you with additional information regarding potential additional services, therapies, etc? *

Is there anything else you'd like for us to know? *

Thank you for requesting a kit! Your kit will be mailed to you within 7 business days.

I understand.

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms