Inquiry Form

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

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?

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:

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? (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.)

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.