Application for Services Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY College(s) Attended (if any) Degree(s) Earned (if any) Previous Employment (if any) Diagnosis (choose one) * Autism Autistic Disorder PDD-NOS Asperger's Disorder Autism Spectrum Disorder Other If Other, please explain What do you hope to learn through the sessions? * How did you hear about Reaching Spectrum Heights? Thank you!
