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About
Events/Fundraisers
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Give Help
- Give Money
  - Angel Society
  - Planned Giving
- Give Time
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- Share Your Story

Self Enrollment

Enrollment Form - Self

Step 1 of 2

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Individual Needing Assistance
If you are 18 yrs or older and need assistance, please fill this section out for yourself.
What Bexar County council district do you live in?
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email
If individual is a child, enter a parent/guardian's email.
Ethnicity*
Race*
Annual Household Income*
For the household where individual resides.
Currently receiving any of the following?*
Check all that apply.
- Supplemental Nutrition Assistance Program (SNAP)
- Child Support
- Women Infants & Children (WIC)
- Social Security Income (SSI)
- NONE of the above
- Other
What other assistance are you receiving?
Currently in school?*
- Yes
- No
If so, where?
Grade or Level
School District
If applicable
Diagnosis*
Or suspicion of a diagnosis.
Primary Care Physician*
If you don't have a PCP, enter NONE.
Date of last or upcoming visit.
MM slash DD slash YYYY
Specialty Physicians
If you aren't seeing a specialty physicians, enter NONE.
Date of last or upcoming visit.
MM slash DD slash YYYY
Insurance Carrier*
Check all that apply.
- Private
- Medicaid
- CHIP
- SKIP
- CSHCN
- Military
- Other Public
- Uninsured
Insurance Policy Number
Marital Status*
Employer*
If unemployed, enter NONE.
Military Status*
What branch of military?*
List all prescription medications the individual needing assistance is currently taking. Press plus button to add more lines.
What other agencies have you received assistance from, been in contact with, or are currently working with?

Pre-Survey
How informed are you about insurance or other medical/prescription assistance programs for individuals with special health care needs?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
How informed are you about programs that provide basic and financial assistance?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
How informed are you about community resources?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
How informed are you about your or your child’s health condition or medical needs?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
Do you have a family doctor or other place you or your child usually go for medical care?*
- Yes
- No
How informed are you on Child Abuse Risk Factors?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
How informed are you on how to report family violence (domestic abuse, child abuse/neglect)?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
How informed are you on strategies on how to cope with stress?*
- Very Informed
- Somewhat Informed
- Barely Informed
- Not Informed
Have you had to visit the ER due to no medication access?*
- Yes
- No
Have you or your child had to go without medication because you could not afford them?*
- Yes
- No
Can we contact you via text message?*
- Yes
- No
Are you participating in Autism Lifeline Links (ALL)?*
- Yes
- No
Which program are you most interested in?*
Choose the program that you would like to meet with first.
Upload Documents
The following documents are not required, however if you feel it will help us understand your needs, please upload the following if available. - Copy of diagnosis (medical record; Admission, Review and Dismissal (ARD); Individualized Education Program (IEP)
Drop files here or

Max. file size: 128 MB.
Phone
This field is for validation purposes and should be left unchanged.

Raising a child with special healthcare needs is difficult. Finding help shouldn't be.

Any Baby Can services are provided at no cost, regardless of income, to families with a child birth through 17 years old with ANY medical diagnosis, incl. chronic illness, disability, developmental delay, or health risk.

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217 Howard, San Antonio, Texas 78212

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