### 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.

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#### “Alone We Can Do So Little; Together We Can Do So Much.”

```
–Helen Keller
```

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### Ascent Family Training Sign Up Form

#### About Your Child

- Your child's name*
  - First Name
  - Last Name

- Your Child's Age*

- Your child's gender*
  - Male
  - Female
  - Non-Binary

- In what states does your child live in?
  - Please Select
  - Alabama
  - Alaska
  - Arizona
  - Arkansas
  - California
  - Colorado
  - Connecticut
  - Delaware
  - District of Columbia
  - Florida
  - Georgia
  - Hawaii
  - Idaho
  - Illinois
  - Indiana
  - Iowa
  - Kansas
  - Kentucky
  - Louisiana
  - Maine
  - Maryland
  - Massachusetts
  - Michigan
  - Minnesota
  - Mississippi
  - Missouri
  - Montana
  - Nebraska
  - Nevada
  - New Hampshire
  - New Jersey
  - New Mexico
  - New York
  - North Carolina
  - North Dakota
  - Ohio
  - Oklahoma
  - Oregon
  - Pennsylvania
  - Rhode Island
  - South Carolina
  - South Dakota
  - Tennessee
  - Texas
  - Utah
  - Vermont
  - Virginia
  - Washington
  - West Virginia
  - 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?
  - We will use this information to match your child with peers.

- Please describe what your child's availability is throughout the week including on the weekend.
  - We will use this information to match your child with a peer group that meets at a time that is convenient for your child.

#### 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

- How did you hear about us?
  - Search Engine (Google, Yahoo, etc.)
  - Social Media (Facebook, Instagram, etc)
  - Recommended by friend or colleague
  - Referring Provider (e.g. Pediatrician, SLP, etc.)

- Submit