Late Diagnosis Autism Support Group Enrollment Request

Legal Name* This field is required.First & Last Legal Name

First Name

Last Name

Preferred NameType your answer.

Preferred Name

Date of Birth* This field is required.Format: MM/DD/YYYY

MM/DD/YYYY

Contact InformationEnter your phone number and select a voicemail preference

Please enter your phone

Is it okay to leave a voicemail at the contact number provided?

Address* This field is required.Type your answer

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

E-mail* This field is required.Type your answer

example@example.com

Sex Assigned at Birth* This field is required.Choose the best fit option

Gender Identity* This field is required.Type your answer.

Prononus* This field is required.Select one

She/Her

They/Them

He/Him

Ze/Zer

Other

What is/are your neurodivergent identity(ies)?* This field is required.Select all that apply

Autistic/Autism Spectrum

ADHD

Other

At what age(s) were you self/documented diagnosed?* This field is required.Type your answer.

Do you prefer identity first (Autistic) or person first (Person with Autism) language?* This field is required.Select the best fit

List previous mental health diagnosis'* This field is required.Type your answer.

If you have a current mental health provider...Type your answer.

Provider Full Name

Place of Service/Location

Provider Phone Number

Referral -- How did you hear about the specific group therapy at Dirkse?Type your answer.

How do you plan to pay for services?* This field is required.Choose one

Cash pay/Out of pocket

Insurance

Other

If you selected to use your insurance coverage, please provide this information.* This field is required.Type your answer. Use "NA" if you are not planning to use insurance to pay for services.

Insurance Plan

Policy Number

If the Provider/Therapist does not accept your insurance, can you pay for the service out of pocket/cash pay?* This field is required.Select the best fit option.

Yes

I'm not using insurance coverage

Maybe

THIS IS AN ONLINE-ONLY GROUP. However, it is possible that an in-person option may be available in the future if enough people are interested. How do you prefer to meet?* This field is required.Select One

Online (i.e., Zoom, telemedicine, etc.)

In-person

Emergency Contact Information* This field is required.Type your answer

Contact Name

Contact Phone Number

Relationship to Contact

What are you hoping to get out of the group therapy experience? What are your goals?* This field is required.Type your answer

Part of group may include psycho-education and discussion on neurodivergent topics. Are there any topics you are interested in learning more about? To name a few...* This field is required.Select all that apply

Monotropism

Hyperfixation/Hyperfocus

Glimmers

Persistent drive for autonomy (PDA or persistent demand avoidance)

What is the neurodiversity paradigm?

Intersection of gender/sexuality and Autism

Overlap of ADHD and Autism (or other diagnosis overlaps)

Masking

7 Types of rest

Autism and sleep issues

Executive function

Double empathy problem

Coke bottle effect

Infodumping

Sensory profiles

Neurodivergent relationships

Stimming

Interoception

Alexithymia/Autism and emotions

Autistic burnout

Autism and the nervous system

Spoon theory

Other

What are you most looking forward to in the group experience?* This field is required.Type your answer

Late Diagnosis Autism Support Group Enrollment Request