Autism Urban Connections Inc. Community Crisis Support Needs
Autism Urban Connections Inc. is here to support you during your time of living in social-distancing during the COVID-19 Crisis. So, we are requesting your suggestions of needs that you and your family are experiencing and may experience during this time. Please help us to assist you and your family by completing this form and remember to think long-term as we work this through together. If you are requesting pampers/pullups please indicate the size needed. We are here to support you!!!
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Email *
Name *
Phone Number *
Complete Address, Including Zip Code *
Number of people in the home *
Name, age, and gender of each child in household *
Ethnicity *
Are any of the children diagnosed with Autism or related disorders (ADHD, ODD, Conduct Disorder)? Please answer based on your level of comfort. *
Are there any adults in the home that has an Autism diagnosis or Mental Health diagnosis. Please share based on your level of comfort. *
Do you receive any benefits or subsidies? Check all that apply. *
Required
Are you connected to any DHS program? Check all that apply *
Required
Are you interested in join our support group? Why or why not? *
What are you finding that you need most to have to provide for you and your family? *
What are you to most likely need in the next 30-60 days? *
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