Piece of Mind Grant Application

  • Demographic Information

  • Refers to person with ASD
  • Please enter a value between 0 and 90.
    Refers to person with ASD
    Refers to person with ASD
  • Person completing application
  • Person completing application
  • Person completing application
    Mark only one
  • Financial Need Section

    Information supplied in this section will help determine financial need assistance.
  • Product Requested

    Please use this section to provide specific information to the products or services that are being requested.
  • What's Next

    Applicants will receive a letter or email stating if they have been selected as a finalist. At that point, the applicant will asked to provide 1. First page of current signed Federal Tax Form 1040 2. Documentation of the disability from the doctor other qualified health professional 3. HIPPA Release form. PLEASE DO NOT PROVIDE THIS INFORMATION UNLESS ASKED. Grant applications and documentation will not be returned to the applicant.
  • Thank you for applying for the Piece of Mind Grant

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