Autism Urban Connections Inc. Circles of Care Registration Form Cohort 5
Autism Urban Connections Inc. is here to support you during your time of living in uncertain times as a residual of the COVID-19 Pandemic. More and more families stand in the need of support and are still struggling in many areas of life. So we introduce to you Circles of Care, this is a 6-week program that gives family members of loved ones on the Spectrum and related disorders an opportunity to learn a multitude of skills and techniques to assist the family in having a better quality of life. Each participant will receive a certificate of completion and may even have an opportunity to become a volunteer family engagement peer support to the new cohorts to follow. There are only 25 slots per cohort, so don't wait to get your registration in soon! You must complete 5 out of 6-weeks to receive certificate of completion, all session material, and our swag bag with self-defense items and a $20 Visa Gift Card. So, we are requesting that you complete this form in its entirety to ensure that each participant receives items after completion . Please do not hesitate to contact us for more information at 412-812-3091 or to find out about additional supports.

Email *
Full name *
Phone Number *
Complete Address, Including Zip Code *
Number of people in the home *
Name, age, and gender of each child in household *
Ethnicity *
Are any of the children diagnosed with Autism or related disorders (ADHD, ODD, Conduct Disorder)? Please explain. *
Are there any adults in the home that has an Autism diagnosis or Mental Health diagnosis? Please explain. *
Do you receive any benefits or subsidies? Check all that apply. *
Required
Are you connected to any DHS program? Check all that apply *
Required
Why are you interested in joining our 6-week Circles of Care curriculum? *
What additional supports can AUC Inc. offer to assist in a good quality of life? *
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