Free Haircut Program Sponsored by Embry Care
Embry Care Services is providing free haircuts to adults aged 18 or older who have a diagnosis of Autism Spectrum Disorder, Intellectual Disability, Developmental Academic Disorder, or Developmental Delay. The program collaborates with licensed and insured local barbershops and travel barbers to create a friendly environment for individuals with special needs. The goal is to assist those who may lack resources for special-needs-friendly haircuts.

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Email *
Name  *
Phone number *
Please enter your location i.e. city, state, zip code etc. *
Are you requesting a haircut for someone else or yourself? *
If someone else, how many number of adults would be receiving haircuts?
Do you or the individual(s) already have a preferred barber?
*
Are you or the individual(s) able to travel locally to receive a free haircut? *
Are there any behavioral concerns (i.e. kicking, biting, pinching etc.) our staff should know about prior to haircuts? If so, please state below.  *
Does you or the individual(s) currently receive services with a home care provider? *
If applicable, what waiver program are you and/or the individual(s) with? *
Does Embry Care have permission to talk with you and/or the individuals about the home care services that we provide?  *
If yes, would you be interested in learning about our $2,000 referral bonus? 
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Are you interested in getting paid to take care of your loved one? 
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