Autistic Mental Health & Well-Being Registration Form

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Autistic Mental Health & Well-Being Registration Form - CLTS Waiver/IRIS/Family Care

To ensure a smooth billing process, we ask that this form is completed by the Service Coordinator/Billing Contact for this registration, NOT the registrant/client. Please fill out a separate form for each registrant.

If you wish to pay by credit card, please click here.

Contact Amber LeFevre at alefevre@autismgreaterwi.org or 920-558-4600 if you have any questions regarding the registration process.

Please enter your email address below to receive a copy of this form upon completion.

Email *

Registrant Information

First & Last Name of Registrant: *

Email Address of Registrant: *

Phone Number of Registrant: *

Mailing Address of Registrant: *

Please Include Street Address, City & Zip Code

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