REQUEST OUR SERVICES
We Look Forward
to Speaking With You
Expect an email from efitch@wholeselfcenter.com or jthompson@wholeselfcenter.com.
Our primary goal is to support your child to grow to become as
self-sufficient
as possible. Our approach is to rely on your input and on our genuine interest in your child to develop a trusting relationship with them that will help promote learning.
We see your child as a Whole Self. (1) We value who your child
IS
as a person, and (2) We strive to understand your child’s unique autism characteristics so we can build on what your child can
DO
to feel more confident every day.
Is your child on the Maryland Medical Assistance Autism Waiver?
Yes
No
Child's Name, Age, and Gender
First Name
Last Name
Age
Gender
Male
Female
Parent/Guardian 1
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
General Information
Address
City
State
Select a State
Maryland
Delaware
Pennsylvania
Virginia
West Virginia
Washington D.C.
Zip
Email
Phone
What services(s) are you applying for?
Intensive Individual Support Services
Respite Care
Therapeutic Integration
Family Consultation
Adult Life Planning
Not Sure
For what county are you requesting services?
County
Have you used waiver services from other providers in the past?
Yes
No
Do you have a person(s) you’d like us to hire?
Yes
No
If yes, please provide their name(s) and phone Number(s)
What is your child's mode of communication?
Check all that apply
Gestures
Handing you an object for what they want
Sign Language
Picture Exchange Communication System (PECS)
Augmentative Communicative Device
Facilitated Communication
Writing
Verbal Language
Does your child have any medical or other special needs?
Check all that apply
Requires Medication
Requires Emergency Seize Medication
Requires Sensory Diet Experiences
Toileting Issues
Special Diet
Food Allergies
Environment Allergies
Unique or Unusual Fears
Other, Please Specify:
What kinds of support service opportunities would you like The Whole Self Center to provide to your child?
Check all that apply
Community Outings
Social Experiences
Home Independence
Tolerating New Environments
Tolerating New People
Developing Flexibility
Developing Greater Self Awareness
Expanding Interests
Engaging in Leisure Activities
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?
Now that you have completed your Family Request Services form, you will be contacted by our office manager soon.
If you wish, you are welcome to contact us at
410-923-1100
Submit