Registration Form

Registration Form

Fill out the form carefully for registration
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Number*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Emergency Contact Email*
example@example.com
Are you a current or previous client of AATC?*
Would you prefer to meet virtually or in person at our office in the Plaza Midwood area of Charlotte (933 Louise Ave #101, Charlotte, NC 28204)?*
Do you identify as autistic or neurodivergent?*
If you identify with another area of neurodivergence other than autism, please share it below.*
Have you received a formal diagnosis of the area you identify with? (No worries if not, we honor self-identification as well.)*
Do you have a strong preference for a type of grouping you feel most comfortable with? (We will do our best to group by age/life-stage as much as possible.)*
Are you a parent?*
Are you a student?*
How did you hear about us?*
Please select any interest areas you have:*

CraftingVisual ArtMusicVideo gamesOther types of gamesGardeningCodingCarsHistorySciencePsychologyUnderstanding neurodivergenceLearning about anything
Please share any other areas of interest that you would like us to know that aren't listed above:
Do you feel like you are actively in burn-out or at the edge of burn-out?*
Are there certain days that work best for you? (*We will use this to identify potential groups/group days, but we can not guarantee options that match your preferred days).*

MondayTuesdayWednesdayThursdayFridayI'm flexible on which day.
Are there certain times of day that typically work best? (Please keep in mind that late afternoon/early evening hours are more in demand and most often reserved for school-age students. Times are based on EST.)*

Morning (9-11 AM)Mid-Day (11-2)Afternoon (2-4 PM)Evening (4-7 PM)I'm flexible on time.
Would you like to inquire about a reduced rate spot for a Support Pod? (Reduced rate spots are very limited and based on need.)*

YesNo
Anything else you would like us to know about you? (If you are not a current or previous client, you'll also have a chance to share other important information on your Get Acquainted Call with us.)
Once your form is complete, please click here to schedule a Get Acquainted Call with us if you are not a current or former client.
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Registration Form

Once your form is complete, please click here to schedule a Get Acquainted Call with us if you are not a current or former client.