Adult Social Group

Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Birthdate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Can you receive text messages at this phone number?

YesNo
What is your email?
Please check all the communication forms you utilize below

EmailTextingCell PhoneSocial MediaNone

Health Background
What age were you diagnosed with autism?
Do you have any other diagnoses that we should know about?

YesNo
If yes, please list below
Do you work currently with any other service providers, check all that apply

Michigan Rehabilitation Services - MRSSpeech TherapistOccupational TherapistCommunity Mental Health - LifewaysROI - Residential Options, IncKit YoungPersonal Therapy Counseling