### We’re Glad You Are Here.

Ascent Autism provides programs to help individuals with autism improve their social skills and communication abilities through group therapy sessions led by trained therapists.

#### “Alone We Can Do So Little; Together We Can Do So Much.”
```  
–Helen Keller  
```  
### Apply for your child.

(N) Ascent Sign Up Form

**Fields Completed** 0/11

- # About Your Child
  - Your child's name*  
    First Name Last Name
  - Your child's date of birth?*  
    /Month /Day Year  
  - Your child's gender?*  
    Male Female Non-Binary
  - In what states does your child live in?*  
    Please Select Alabama Alaska ... Wisconsin Wyoming

- Does your child have any speech or language challenges? If yes, please describe them.
- What are your child's strengths?
- How does your child best communicate?  
    E.g. Verbally
- Please describe your child's specific interests?  
- Please describe what your child's availability is throughout the week including on the weekend.

- # About Yourself  
  - Your Name*  
    First Name Last Name  
  - Your Contact Number*  
    Format: (000) 000-0000.  
  - What time of day is best for you to receive calls?  
    Morning (8 - 11AM) Noon (11AM - 1PM) Afternoon (1 - 4PM) Evening (4-8PM)
  - Your email address?*  
    example@example.com  
  - What is your relationship to your child?  
    Mom Dad Grandparents Other
  - Are you interested in:  
    Social Skills Group Therapy One-on-One Sessions Family Training
  - How did you hear about us?  
    Search Engine (Google, Yahoo, etc.) Social Media (Facebook, Instagram, TikTok etc.) Recommended by friend or colleague Referring Provider (e.g. Pediatrician, SLP, etc.)
- Submit