PAC-Relief (Parents of Autistic Children) - Community services for families affected by autism
Thank you for visiting our website. I hope the information provided can be of service to you, a friend, or a love one. I ask that you please complete the form below if you are a parent, or guardian desiring services. All information is confidential, and not shared with any outside sources. Check back often, as data is continuously  added to keep the public abreast of  important  resources and news.
INFORMATION FOR SERVICES
First Name
Last Name
Ph #
Phone #:
Cel
Home
Best Time to Call
Mornings
Evenings
Email
Mailing Address
Emergency Contact: Name / Ph #
Status
Two Parent Home
Single Mother
Separated
Divorce
Grandparent
Other
AUTISTIC PERSON'S INFORMATION
Name
Gender
Male
Female
Age
18 mo. - 3
4 - 6
7 - 9
10 - 12
13 - 15
16 - 18
19 - 21
21 or older
What is their diagnosis?
Autism
Aspergers Syndrome
Pervasive Developmental Disorder (PDD-NOS)
Not Certain
At what age was the diagnosis made?
Communication Skills
Verbal (Can Talk)
Nonverbal (Unable to Speak)
Uses Singular Words
Uses Sentence Fragments
Babbles and Mumbles
Capable of using complete sentences
Name of School
Grade Level
ADDITIONAL INFORMATION TO HELP US TO HELP YOU
Are there other siblings or children in the home, If so how many and what are there ages:
Do you Have a Current Support System?
What is your Support System?
Family Members
Single Family Member
Close Friend
Local Support Group
Religious Organization
None
What services would best benefit you or your family?
Monthly Support Group
Local Resources
Prayer and Words of Encourgaement
Counseling
Recreational Activities
Mom's Night Out
Sibling's Day Out
Weekend Getaway
Respite
Autism Worshops
How would you like to be contacted:
Are there any other concers you have, or comments you would like to provide?
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