Family Request

[Back to Whole Self Center Home]

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 (if more than one child please submit a new application for each)
First Name Last Name

Parent/Guardian 1
First Name Last Name
Parent/Guardian 2
First Name Last Name

Address Line 1
Address Line 2
City State Maryland
Zip Email
Day Phone Evening Phone
example: (301)123-4567 ext.1234 example: (301)123-4567 ext.1234
Best Time to call

What services are you requesting?
Check all that apply.
Family Training
Intensive Individual Support Services
Respite Care
Adult Life Planning
Therapeutic Integration
Not Sure

Are you asking for Autism Early Intervention Services for a Preschooler?

What school does your child attend?

What is your child’s mode of communication?
Check all that apply.
Handing you an object for what he/she wants
Sign Language
Picture Exchange Communication System (PECS)
Augmentative Communication Device
Facilitated Communication
Verbal Language

What type/s of autism treatment programs or supports have you used to help your child’s development? Sign Language
Picture Exchange Communication System (PECS)
Augmentative Communication
Facilitated Communication
Floor Time
Relationship Development Intervention (RDI)
Lovass Programming
Discreet Trials
Applied Behavioral Analysis (ABA)
Verbal Behavior (ABBLS)
Natural Environment Learning (NET)
Use of a Behavior Intervention Plan
Functional Behavior Assessment (FBA)
The TEACCH Program
Pivotal Response Theory (PRT)
Social Communication Emotional Regulation and Transactional Supports (SCERTS)
Not Sure
Other, Please specify:

Have you used waiver services from other providers in the past?

Do you currently have technicians working with your child?

Do you currently have a Family Trainer working with your child?

What is the one thing that The Whole Self Center staff could do to support your child that would help your family the most?

What do you consider to be your child’s greatest strengths?

What kinds of support service opportunities would you like The Whole Self Center to provide your child?
Check all that apply.
Community Outings
Social Experiences
Independent Functioning in the Home
Tolerating New Environments
Tolerating New People
Developing Flexibility
Developing Greater Self Awareness

Does your child have any medical or other special needs.
Check all that apply.
Requires Medication
Requires Emergency Seizure Medication
Requires Sensory Diet Experiences
Toileting Issues
Child/teen is in diapers
Special Diet
Unique or unusual fears
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?