Virtual Cooking Class
Registration Form
Overview
Looking for a way to relax, connect, and nourish your mind and body? Join our Virtual Cooking Class! In this unique group experience, you'll participate in meal planning, budgeting, and learn delicious, easy-to-make recipes. Whether you're looking to reduce stress, find community, improve your independent living skills, or explore emotional wellness through food, this class is the perfect blend for you. The sessions will run virtually every Tuesday 5-6pm and are open to people of all abilities in the state of Ohio.
Date/Time
Tuesday evenings from 5:00p-6:00p EST. This group starts February 4th.
Age Group
16 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
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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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