The Cosey Project Intake Form
Welcome to The Cosey Project! Please share any specific challenges your family is facing, so we can tailor our resources and support to your unique needs. After the information has been received, a member of The Cosey Project will contact you.
Caregiver's Name
*
First Name
Last Name
Child's Name
First Name
Last Name
Child's Age
Does your child have autism?
Yes
No
Does your child have a mental health illness (e.g., anxiety, OCD, PTSD)?
Yes
No
Have your child faced trauma (e.g., accident, death, illness)
Please Select
Yes
No
E-mail
*
Phone Number
-
Area Code
Phone Number
How many individuals live in your home?
1
2
3
4
5
6
7
8
9
10
Would you like to sign up for our monthly meal service?
*
Yes
No
This service occurs once per monthly offering a healthy meal choice for families
.
Would you like to sign up for our annual Toy Giveaway?
Yes
No
Please list any additional information or resources that the family needs (e.g., service for adults, therapy services).
Submit
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