Autism Urban Connections Inc. Assistance Form
Autism Urban Connections Inc. is here to support you and your family! More and more families stand in the need of support and are still struggling with basic needs such as household cleaning products, hygiene items, food, and we assist families needs on an individual basis, so do not hesitate to reach out directly. So, we are requesting that you complete this form in its entirety, as if not completed we can not assist you of needs that you and your family are experiencing and may experience during this time.  Please help us to assist you and your family by completing this form and remember that this form must be completed on a monthly basis, as delivery is once a month. If you are requesting pampers/pull-ups please indicate the size needed and if its male or female.  We are here to support you!!!

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Email *
Essential's
*
Required
Pamper/Pull Up size & Gender
Full Name *
Phone Number *
Complete Address, Including Zip Code *
Number of people in the home *
Name, age, and gender of each person in household *
Ethnicity *
Are any of the children diagnosed with Autism or related disorders (ADHD, ODD, Conduct Disorder)? *
Are there any adults in the home that has an Autism diagnosis or Mental Health diagnosis? *
Do you receive any benefits or subsidies? Check all that apply. *
Required
Are you connected to any DHS program? Check all that apply *
Required
What additional supports can AUC Inc. offer to assist in a good quality of life? *
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