Synergy Autism - Wait List

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hello. Thank you for your interest in services. I would love to meet with you and hear more about your needs however, I am currently very busy serving many other lovely individuals, teams and families. I ask that you fill out this online form to be added to my wait list. The form asks questions about your needs and I will review entries as soon as I am able to respond. Should you have any other questions, please contact me at barbara@synergyautismcenter.com

Email *

Your name *

How did you hear about my services? *

It may be a longer wait time for clients accessing services through the county DD program or other agency. I can only take a certain number of you at a time. How are you planning to access services? (I do not take insurance). *

Privately

County DD Behavioral Support

Washington County Juvenile Correction Services

Other:

Type of support you are seeking *

For myself - to better understand my own autism

For me, as a parent, to better understand my child's autism and how to best support them

For me, as a loved one, to better understand my family member's autism and how to best support them

For me, as a professional, to better understand my client/patient's autism and how to best support them

A combination: to support both my teen/adult child with autism and myself as their parent(s)

Other:

Required

Age of the person with autism or suspected of having autism in your life (your age, if you are wishing for services for you) *

What are you hoping for from my services? *

What type of service are you interested in?

Autistic teen or adult group

Personalized parent/caregiver training sessions

Individualized teen or adult coaching sessions

Personalized couples sessions

Parent/caregiver group

Professionals group

Couples group

Other:

Would you like to be added to my e-newsletter? *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Synergy Autism Center. Report Abuse

Forms