Please complete this form to express interest in our virtual executive function training program for parents. The goal of this program is to help parents learn techniques to improve their child's executive functioning, including emotion regulation, organization, and flexibility.

In order to be eligible, you must be a parent or caregiver of a child with autism spectrum disorder between the ages of 5 and 14 years.

The program will take place over the course of 9 weeks and will be held several times over the course of the year, with the first group beginning at the the beginning of February 2026. Group coaching sessions are 30 minutes and will be held virtually, over Zoom.

We look forward to hearing from you!

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* 1. Your Full Name:

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* 2. Your Child's Full Name:

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* 3. County of Residence

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* 4. Has your child been hospitalized within the past year due to his/her behavior?

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* 5. How old is your child?

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* 6. Contact Information:

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* 7. Please note which times you would be available for a brief phone screen:
(Please select all times that you are available, we will do our best to accommodate your preferences!)

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* 8. Please indicate which time would work best for you for the 30-minute weekly virtual parent coaching session as part of the program.

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