Inquiry Form

Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Age:

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Number

Format: (000) 000-0000.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

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?

About how long has it been since you were diagnosed or began self-identifying as autistic?

If you identify with another area of neurodivergence other than autism, please share it below if you would like us to know.

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?

If you are currently a student or employed, please share briefly about what you do or what you study.

How did you hear about us?

Please select any interest areas you have:

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).

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.)

Would you like to inquire about a reduced rate spot for a Support Pod? (Reduced rate spots are very limited and based on need.)

Anything else you would like us to know about you?

Once your form is complete, you can schedule a Get Acquainted Call here. This is now optional for those who would like to learn more.

It can take time to be matched with a Pod that is a good fit. When we've found a pod that we think might work, we'll reach out via a Google Form in which you can select whether or not that group pairing, date/time works for you.

For other questions you can reach out to rachel@kindculturecommunity.com.

Registration Form

Once your form is complete, you can schedule a Get Acquainted Call here. This is now optional for those who would like to learn more.