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In order to better meet the needs of our patients worldwide, we encourage you to fill out the form below. Once it is submitted, it will be sent to our conference/clinic coordinator and reviewed to determine if it is an area where a future conference or clinic can be held. Thank you for your feedback!

Best Regards,

The Great Plains Laboratory Staff

1. I am interested in the following event(s) to be held in my city/region (check more than one if needed):
Outreach Clinic	Parent Conference	Practitioner Training

2. I have had experience with testing at the Great Plains Laboratory and support the idea that an individual’s potential can be maximized through biomedical treatments and interventions:
Yes	No	Maybe/Depends

3. I would be willing to provide local support in promotions (distributing flyers, emails, posters) and general event planning:
Yes	No	Maybe/ Depends

4. I am a member of a local support group consisting of 15 people or more who would be committed to attending the following: Outreach Clinic:
Yes	No

Parent and/or Practitioner Conference:

Yes	No

5. There is an obvious shortage of resources for individuals with autism and related disorders in my city/region:
Yes	No


6. My community is aware of and open to alternative forms of medicine and treatment:
Yes	No	I don't know

Please fill out the following information so that we may contact you if we decide to plan an event in your area:

Name:
Last Name:
Address:

City:
State/Province:
Postal Code:
Country:
Telephone Number(s):
Email:
If you are sincerely committed to taking on a project like this in your area, please take the time to write a few, short paragraphs (150 words max.) about your networking resources, possible conference locations, availability to mailing lists, knowledge of local government organizations willing to help parents in financial need, access to volunteers, local vendors intereted in exhibiting, etc