Submit a Family Request

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Thank you for taking the time to complete this form.
We will try to respond to your request as quickly as possible.
The questions in red bold lettering are required and you must provide that information.
Is your child on the Maryland Medical Assistance Autism Waiver?
Is your child on the Maryland Medical Assistance Autism Waiver Waiting List/Registry?
Child Information
First Name
Last Name
Age
Parents/Guardians
Parent/Guardian 1
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip
Email
Phone
Example: (123)-456-7890
Other Phone
Example: (123)-456-7890
Best Time to call
What services are you requesting?
Check all that apply (Select at least one).
What school does your child attend?
What is your child's mode of communication?
Check all that apply.
What type/s of autism treatment programs or supports have you used to help your child's development?
Other, Please specify:
Have you used waiver services from other providers in the past?
What kinds of support service opportunities would you like The Whole Self Center to provide your child?
Check all that apply.
Does your child have any medical or other special needs.
Check all that apply.
Other, please specify:
How did you learn about us?
Is there any other information you'd like to share with us or request from us?