Interest Form
Community Autism Resources and The Well are joining forces to offer tailored therapy, designed specifically to address the unique needs of autistic individuals of all ages. This will also extend support to families, professionals, and community partners alike.
Please fill out the form below if you would be interested in accessing these services.
Your Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Who would be benefiting from therapy sessions?
Ex. Autistic adult, teen, child - Parent - sibling - care provider - direct support staff
Provide a brief description of why you are interested in seeking therapy at this time.
Please select which office location would be most convenient for you.
Dean St. Taunton (inside the CAR office)
Pleasant St. Bridgewater (same building as Bridgewater Pediatrics)
Main St. Bridgewater (Carriage House)
Oak St. East Bridgewater (Inside Club Ex)
Virtual
What day of the week would be ideal for your sessions?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time
Morning
Afternoon
Evening
What type of insurance do you have?
If available, would you be interested in accessing medication management?
Please Select
Yes
No
Please be advised that this form serves as an initial point of contact for those interested. Upon compilation of information, we will reach out to provide further details regarding the intake process
Submit
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