TACA Talk About Curing Autism - Support

TACA Mentor Application

Please use this form to submit an application for becoming a TACA mentor only. You MUST answer all questions. Please put N/A if the question is not applicable.

Questions? Contact Susan Kristie.

Overview

TACA is looking to help more families affected by autism via our volunteer mentor program. We are expanding this program throughout the United States. Mentors are a crucial part of TACA’s success providing newly diagnosed families the much-needed introduction to autism and the community around their family.

To make sure we adequately understand your knowledge to help newly diagnosed families – please take a few minutes to fill out this application. It will greatly help us assign mentors to the best match. THANK YOU!

TACA Mentor Reference Information

Please read the links about our free service to families in need:

Thank you for taking the time to review, fill out and consider being a TACA mentor. WE TRULY VALUE YOUR DESIRE TO HELP. We will be contacting you within a month to follow up on your application and upcoming mentor training.

Your Name: Last, First

Street Address:

City:

County:

State:

Zip:

Home Phone Number:

Cell Phone Number

Personal Email Address:

Listserves Email Address:

School District:

Do you have a child(ren) with Autism Spectrum Disorder?
yes or no

If yes, child(ren)'s age(s); if no, put N/A:

Does your child(ren) live with you?

Is your child recovered?

How many other children live with you and do they have any diagnosis?

Who is your DAN! doctor?

How long have you been on the biomedical journey?

Who have been your favorite autism professionals (DAN! or other?)

What are the top 3 things that have worked for your child(ren)?

Do you participate in any other autism support groups? If so, which ones?

Have you attended any biomedical conferences or listened to their webcasts? Please list where and when.

Other conferences?

Are you conversational in another language besides English?
Which language? And, would you be willing to mentor in that language?

How long have you been a member of TACA?

On a scale of 1-10, 10 being best, please rate your knowledge in the following areas:

Dietary Intervention

GFCF (1-10)

SCD (1-10)

Other, please specify dietary invention (Specific diet & 1-10)

DAN! Biomedical protocols (1-10)

Prescribed Medications

Psychotropic Medications (1-10)

Other Medications, please specify medications (Specific med & 1-10)

Payment Resources

Medicaid/Waiver (1-10)

Health Insurance (1-10)

Educational Issues (1-10)

Seizures (1-10)

Local Resources (1-10)

Traditional Therapies (1-10)

Please list your top 3 of the above categories:

Is there anything else that you would like to tell us about yourself?

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