Autism Assistance Application

Please complete all information to the best of your knowledge. Due to high volume of applications being submitted, please expect approximately 3-6 weeks to be reviewed. *Times may be extended due to COVID-19.

Autism Application Form

Name of Disabled Party *

First

Last

Check box if disabled party is the primary contact.

Name of Primary Contact *

First

Last

Phone Number for Primary Contact *

Email *

Confirm Email *

Address of Disabled Party *

Address of Disabled Party

City

State/Country

Zip/Postal

Country

List the applicant’s primary medical care provider who most often treats the individual. This may be a psychiatrist, psychologist, counselor, or therapist, along with the email and physical address of the provider. *

Medical Provider's Phone *

Address of Primary Healthcare Provider *

Address of Primary Healthcare Provider

City

State/Province

Zip/Postal

Country

Phone

603-374-5156

Mailing Address

1088 US Route 302
Bartlett, NH 03812

Autism Assistance Application

Phone

Mailing Address

Our Services

Our Dogs

About Us

Get Involved

Follow Us

Our Services

Our Dogs

About Us

Get Involved

Follow Us