Resource Booking Form

Providing specialized support for autism families.

1. Are You a NeuroConnect Member?

Yes, I am a registered member No, I am not a member

2A. Non-Members – Book Your Induction Webinar

To access NeuroConnect services, non-members must attend an induction webinar.

Webinar Schedule

Every Saturday, 9:00 AM - 11:00 AM

M-PESA Payment Reference

Would you like a reminder?

Yes, send me an SMS Yes, send me an email

2B. Members – Proceed to Book Services

3. Parent/Guardian Information

Full Name

Email Address

Phone Number

4. Child's Age Group

5. Select the Resource You Need

Assessment (Initial evaluation of the child's needs) Counsellor One-on-One Nanny Training Webinar Nanny Training (Paid) Individualized Education Plan (IEP) Occupational Therapist Speech Therapist ABA Therapist Request a Specialist Book a Webinar (Paid)

6. Webinar Booking

Choose a Webinar

Payment Confirmation

7. Preferred Session Type

In-person Virtual (Zoom/Google Meet)

8. Preferred Date & Time

Preferred Date

Preferred Time

9. Additional Notes or Special Requests

10. How Did You Hear About NeuroConnect?

Please specify

11. Payment Agreement

I acknowledge that webinar bookings and assessments require payment, and I will submit proof of payment before my session is confirmed.

12. Consent & Agreement

I agree that my information will be used solely for booking and service provision, in line with NeuroConnect's privacy policy.

13. Would You Like to Receive Automated Confirmations?

Yes, send me an SMS confirmation Yes, send me an email confirmation No, I'll check my status manually

Thank you for your request!

We've received your information and will contact you within 24-48 hours to discuss your needs and schedule your service.