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Full Name (Required)
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Person Making Request
Your Email
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Phone Number (Required)
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City/County (Required)
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Child's information
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First
Last
Age
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Has the Child been screened for Autism?
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— Select Choice —
Yes
No
the Number of
What Type of Support or services are You Requesting?
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— Select Choice —
Autism Evaluation
IEP Support
Other
Briefly describe your situation.
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Please tell us about your current situation, needs, and any challenges you’re facing.
Household Income:
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Less than $30,000
$30,000 – $40,000
$40,000 – $50,000
$50,000-$55,000
Above $55,000
Insurance
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Do you have insurance? If so, please provide the name of the insurance provider.
AGREEMENT:
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I Agree with the below statment
I DO NOT Agree with the below statment
By submitting this form, you are confirming that you have provided accurate information to the best of your knowledge. Furthermore, you understand that this is a request and not a guarantee by LAEF to provide you with requested or any services.
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