Supports & Services Form

PAN’s Service Provider Directory

The Penn Autism Network (PAN) receives many inquiries from adults with autism spectrum disorders (ASD) and their families who are seeking supports and services. If you are a service provider to adults and those transitioning to adulthood, please submit your information for inclusion in our directory. If you are not a service provider but would like to share information about a resource to be considered for the directory, give us as much information as possible and we will contact the provider for additional details. PAN will make this directory available in early 2009.

Note: Asterisks (*) indicate required fields

I am a representative of a service or supports provider. I am recommending a service or supports provider.

Provider Information
First Name:
Last Name:
Suffix:
Title:
* Organization:
Department:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* County:
* Phone 1:
Phone 2:
Email:
URL:

* Services Offered

Advocacy Assessments Case Management Dentist Employment Services Evaluations Financial Planner Group Therapy Housing Legal Services Medical Doctor Neuropsychologist Online Community Psychologist Psychiatrist Recreation Research Seminars/Conferences Social Worker Support for Families Support for Individuals Social Skills Training Other

Ages Served

(indicate all categories served; note that the PAN database is meant to provide resources for adults with autism, those transitioning to adulthood, and their families):

21+ 18-21 12-17 5-11 Birth-4

Method of Payment

Private Insurance (please indicate types of insurance accepted) Medical Assistance Other Not Applicable

Service Locations by County

PA Counties		NJ Counties		DE Counties
	ADAMS		ATLANTIC		KENT
	ALLEGHENY		BERGEN		NEW CASTLE
	ARMSTRONG		BURLINGTON		SUSSEX
	BEAVER		CAMDEN
	BEDFORD		CAPE MAY
	BERKS		CUMBERLAND
	BLAIR		ESSEX
	BRADFORD		GLOUCESTER
	BUCKS		HUDSON
	BUTLER		HUNTERDON
	CAMBRIA		MERCER
	CAMERON		MIDDLESEX
	CARBON		MONMOUTH
	CENTRE		MORRIS
	CHESTER		OCEAN
	CLARION		PASSAIC
	CLEARFIELD		SALEM
	CLINTON		SOMERSET
	COLUMBIA		SUSSEX
	CRAWFORD		UNION
	CUMBERLAND		WARREN
	DAUPHIN
	DELAWARE
	ELK
	ERIE
	FAYETTE
	FOREST
	FRANKLIN
	FULTON
	GREENE
	HUNTINGDON
	INDIANA
	JEFFERSON
	JUNIATA
	LACKAWANNA
	LANCASTER
	LEBANON
	LEHIGH
	LUZERNE
	LYCOMING
	MCKEAN
	MERCER
	MIFFLIN
	MONROE
	MONTGOMERY
	MONTOUR
	NORTHAMPTON
	NORTHUMBERLAND
	PERRY
	PHILADELPHIA
	PIKE
	POTTER
	SCHUYLKILL
	SNYDER
	SOMERSET
	SULLIVAN
	SUSQUEHANNA
	TIOGA
	UNION
	VENANGO
	WARREN
	WASHINGTON
	WAYNE
	WESTMORELAND
	WYOMING
	YORK

Person Completing Form
* Name of person completing form:
* Phone of person completing form:
* Email of person completing form:
Additional Info: