Neurodivergent Community Group
Registration Form
Overview
Join our Virtual Neurodivergent Community Group, a supportive and inclusive space where neurodivergent adults can connect, share experiences, participate in activities and build meaningful relationships. Whether you're seeking understanding, peer support, or simply a place where you can be yourself, we welcome you to join our participant-driven group. The sessions will run virtually every Wednesday 7-8pm and are open to people of all abilities in the state of Ohio.
Date/Time
Wednesday evenings from 7:00p-8:00p EST. This group starts February 12th.
Age Group
18 years of age and older.
Location:
Virtual. Zoom link will be sent once registration is confirmed.
Participant's Legal Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Is the participant a current counseling client at Avenues for Autism?
*
Yes
No
If the participant is a current client, what source of funding will they be using?
*
Medicaid
Private Pay (approximately $30 per session)
Commercial Insurance
N/A - not a current client
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Legal sex of the client (required by insurance):
*
Male
Female
Please enter the client's gender identity and preferred pronouns:
*
Client's Race & Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Other
Client's address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary language spoken in the home:
*
Please also note if you or the client requests an interpreter.
Name of client's emergency contact:
*
First Name
Last Name
Relationship to client:
*
Biological parent
Adoptive parent
Legal guardian
Other
Emergency contact address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact telephone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact email address:
*
example@example.com
Email address for zoom link:
*
example@example.com
Do you consent to receiving text messages and emails from Avenues for Autism including appointment reminders and instructions on scheduling?
*
Yes
No (Please call our office to discuss)
For identity verification purposes, please upload a copy of the client's driver's license.
*
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What source of funding will you be using?
*
Medicaid
Private Pay (approximately $30 per session)
Commercial Insurance
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Name of insurance company:
*
Aetna
AmeriHealth Caritas
Anthem/Blue Cross Blue Shield
Buckeye Community Health Plan
CareSource
Humana
Medical Mutual of Ohio
Molina
Paramount
United Healthcare
Other
Front of insurance card:
*
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Back of insurance card:
*
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Name of person completing this form:
*
First Name
Last Name
Who referred you to our services?
*
Please provide any additional information here. We look forward to speaking with you.
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