My Meredith - Submit application - Meredith Autism Program (M.A.P.) Application for Services

Guardian or Caregiver 1

Name*

Relationship to child*

Occupation (optional)

Are you the child's legal guardian or caregiver?*

Legal guardian

Caregiver

Would you like to add information for a second Guardian or Caregiver?*

Yes

Contact Information

Address Line 1*

Address Line 2

City*

State*

Zip*

Does the child reside at this address?*

Yes

Best Contact Phone Number*

Email address*

Preferred Method of Contact (select all that apply)*

Phone

Text

Diagnosis and Other Information

Date of Diagnosis*

Place of Diagnosis*

Name of the pediatrician*

Who is your insurance carrier? Ex: Aetna, BCBS*

Please list any services that the child is currently receiving (speech therapy, occupational therapy, physical therapy, therapeutic preschool, typical preschool, etc.):*

Please list your major concerns about your child at the present time:*

Please describe how your child currently communicates with you:*

Please describe any restrictive or maladaptive behaviors in which the child has ever engaged:*

Unfortunately this type of program costs close to $40,000 per year (without insurance coverage). MAP does not offer payment plans for services and while we do have scholarship opportunities, these are not guaranteed.

Please explain how you would maintain your child's services in this program for over 2 years if accepted:*

Please tell us why you decided upon this particular type of intervention for your child:*

How did you hear about our services:*

Family/friend

Meredith Alumni

Google Search

Personal Research

Social Media

Diagnosis Center

Pediatrician

Other

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