Supporting Your Autistic Child Through Anxiety- Interest Form

Please complete this form to express interest in our virtual parent training program for parents of an autistic child with anxiety. The goal of this program is to help parents learn techniques to manage their child's anxiety.

The program will take place on Thursdays from 9-10 am OR 10-11 am, beginning March 5th, for 8 weeks. Sessions are 60 minutes in length and will take place via Zoom.

In order to be eligible for this program, you must be (a) a parent or caregiver of a child with autism spectrum disorder between the ages of 6 and 10 years, and (b) have a child struggling with anxiety.

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

Albany

Columbia

Fulton

Greene

Hamilton

Montgomery

Rensselaer

Saratoga

Schoharie

Schenectady

Warren

Washington

Other (please specify)

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* 4. Child's Date of Birth

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* 5. Does your child have an autism spectrum diagnosis?

Yes, my child has an official autism spectrum diagnosis

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* 6. Child's Language Ability

No current gestures or verbal language

Uses gestures, but no current verbal language (Hand-leading, signs, pointing, etc.)

1-2 word phrases

3-4 word phrases

Sentences

Other (please specify)

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* 7. Child's Classroom Type

General Classroom

Integrated Classroom

Self-Contained Classroom

Other (please specify)

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* 8. Please briefly describe if your child has a diagnosed anxiety disorder and how it impacts your family's quality of life.

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* 9. Is your child currently receiving psychotherapy for their anxiety?

Yes

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* 10. Please pick which time works best for you.

Thursday, 9-10 am

Thursday, 10-11 am

Either time works for me

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* 11. Contact Information:

Email Address

Phone Number