Organization Inquiry - Greenwood Interprofessional Autism Center

Greenwood Interprofessional Autism Center

Organization Inquiry Form

This form is for school districts or other organizations seeking support for one or more patients.

Filling out this form does not imply a commitment from either party.

If Greenwood Interprofessional Autism Center is a good fit for your organization, we will request more detailed information. Please provide some preliminary information so we can better understand your needs.

Name of Organizational Entity Inquiring*

Please share a bit about your organization and services*

Contact name*

Email*

Phone*

Address*

Description of services sought*

Preferred service location(s) - select all that apply
Our goal is to build our program around our center-based services. We are interested to know the need in other settings, but at this point, that is more for informational purposes.
*

Greenwood Interprofessional Autism Center

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School (specify below)*

* Specify "School"

Please describe anticipated funding mechanism(s)
(i.e., which insurance, through school and if so which school/district so we can reach out, some other grant or waiver, private pay, or if none or unsure, please state that)*

Other info you'd like to share

How did you hear about us*

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