SERVICE PROVIDER INFORMATION

The mission of THE PALMETTO PARTNERSHIP of All 4 Autism is to increase the quality of life of those with disabilities, and their families, by providing free resources, support and advocacy services, while actively seeking opportunities to partner with others and serve as ambassadors of goodwill in our community. We are a grassroots organization, and all of our services are free and open to the public.

Family Consultation is one of the support services we offer. We provide families with information packets with local, regional and state service providers and resources. We would like to include information about your company, and the services you provide, in our packets and our digital resource links.

We truly appreciate you taking the time to complete the information below.

For more information, please contact us at info@palmettopartnership.org or 843-472-5215. Visit our website at: www.palmettopartnership.org.

THANK YOU!

Company/Agency Information

Business Name *

Physical Address *

Mailing Address (if different than physical address)

Contact Information

First Name *

Last Name *

Title

Phone Number *

Email Address *

Insurance

Do you accept Medicaid? *

Do you accept private insurance? *

If yes, please provide the names of all insurance companies you accept:

Services

What services do you provide? *

What ages do you serve? *

Referrals

Is a referral for services required? *

If yes, what is an acceptable referral?

Thank you for your time. This information helps our organization provide the support and resources needed for our under-served community, and those with disabilities.

If you would like to receive information about our programs and services, please enter your email address: