Contact Information Form

Thank you for contacting the Strong Center for Developmental Disabilities.

This page is an information form to collect your contact information and for us to learn about your reason for contacting us.

Depending on the reason, when you click "Next Form" at the bottom of the page, you will be directed to provide more information specific to your request.

Requests for resources, presentations, and survey distribution will be answered by the Rochester Regional Center for Autism Spectrum Disorder (RRCASD)
Requests for Communications and Web assistance will be answered by our communication team
All other requests will be reviewed and you will be contacted by someone who can help you

Date

M-D-Y

Name

Phone Number

Email Address

* must provide value

Which of the following describes your reason for contact?

I am looking for Autism Spectrum or other neurodevelopmental disorder support or diagnosis for myself

I am a parent, guardian, or family member looking for Autism Spectrum or other neurodevelopmental disorder support or diagnosis for someone or support resources for myself

I am a community provider and looking for Autism Spectrum or other neurodevelopmental disorder support or diagnosis for a client

I want to request a presentation for a school, community agency, parent group, or employer about Autism Spectrum Disorder or other neurodevelopmental disorders

I have a survey or research study I want to distribute through your network

Other

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Please specify "other" request

Someone will reach out to you to resolve your request

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State

City

County

Is the individual a child (under 18 years of age)?

Yes

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Mark field as:

[Clear value]

Not applicable (NA)

Unknown (UNK)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.