Form – AKOS 4 AUTISM

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Online Application Form for Sponsored Treatment

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Confidential Morbidity Form (#3)

Parent/Guardian Information

Parent/Guardian's Name (First Name)

Last Name

Relationship to Child

Please Specify Relationship

Phone/Mobile

Facility Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Child’s Information

Child’s First Name

Last Name

Date of Birth

Gender

Diagnosis Status

Diagnosed

Undergoing Evaluation

Date of Diagnosis

Any Other Medical Conditions

Yes

If Yes, please specify

Tell Us Your Story

Describe your child’s journey with autism. What makes their story unique?

What challenges has your child faced due to autism?

What are some positive aspects of their journey?

Explain Your "WHY"

Why is this treatment important for your child?

What are your hopes and dreams for their future?

How do you believe our targeted treatment will help?

Diagnosis & Background

How was your child diagnosed?

What treatments or therapies has your child received so far?

Speech Therapy

Occupational Therapy

Behavioral Therapy (ABA)

Special Education Services

Medication

Other

Please specify

Has your child participated in any other autism-related programs?

Yes

If Yes,Please specify

Family & Financial Situation

Are you currently receiving any financial assistance for autism treatment?

Yes

If Yes, from where?

What are the biggest financial challenges in accessing treatment?

Additional Information & File Uploads

Is there anything else you would like us to know?

Upload Supporting Documents

Diagnosis Reports

Doctor’s Notes

Therapy Reports

Upload Diagnosis Reports

Choose File

Upload Doctor’s Notes

Choose File

Upload Therapy Reports

Choose File

Consent & Submission

I confirm that all information provided is accurate and I consent to my child’s application being reviewed by AKOS 4 AUTISM

I have read and agree to the Terms and Conditions and Privacy Policy

Akos 4 Autism is dedicated to finding a cure for autism by shifting away from outdated behavioral diagnoses.

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