Share: Facebook LinkedIn Email LifeNet Contact Form Contact information By submitting this form, you are opting in to email communication from AANE. You may update your email preferences at any time by clicking the unsubscribe link at the bottom of AANE emails, excluding confirmation and reminder emails. Your First Name* Your Last Name* Email* Enter Email Confirm Email Primary phone number* Type of phone*Mobile Personal PhoneLandline Personal PhoneWork PhoneLocation Information:Street Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPostal Code* Country*United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsAffiliationI am a/an... (choose all that apply)**Please check all boxes that apply to you.Adult with an Asperger/autism profile Teen with an Asperger/autism profile Parent of adult with an Asperger/autism profile Parent of teen with an Asperger/autism profile Parent of child with an Asperger/autism profile Sibling of an individual with an Asperger/autism profile Grandparent of an individual with an Asperger/autism profile Partner/spouse of an individual with an Asperger/autism profile Ex-Partner/spouse of an individual with an Asperger/autism profile Individual whose parent has an Asperger/autism profile Other family member of an individual with an Asperger/autism profile Educator who works with those with Asperger/autism profiles Other professional who works with those with Asperger/autism profiles Friend of an individual with an Asperger/autism profile No relationship, interested in learning more First Name of person you are contacting us about* Last Name of person you are contacting us about* Is this your first contact with AANE?*Yes No How did you hear about us?*Internet searchEmail from AANEEducator/ProfessionalFamily/FriendSocial MediaPrint MediaConference/Educational EventOther parentsResource fairOtherProspective Client's Age* Prospective Client's Living Situation:*In family home with parent(s) and/or other relatives In group home/supported residence with other adults In own apartment, condo, or home Other (you can explain in the comments box below) Prospective Client's Home Zip Code (If different from above) Level of LifeNet service I'm interested in getting more details about:Comprehensive (top level) Basic (mid level) Introductory (entry level) I'm not sure Comments/additional information you would like to share: Demographic information (optional)By filling out these fields, you help us gain insight into how we can help our entire community. Your personal information is protected by our privacy policy and is not shared with anyone outside of AANE.Birth YearFor person with an Asperger/autism/neurodiverse profilePlease select2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900GenderFor person with an Asperger/autism/neurodiverse profilePlease selectFemaleMaleNon-binaryPronounsFor person with an Asperger/autism/neurodiverse profile.Please selectHe/him/hisShe/her/hersThey/them/theirsEthnicityFor person with an Asperger/autism/neurodiverse profile. Please selectHispanic/LatinxNot Hispanic/LatinxRaceFor person with an Asperger/autism/neurodiverse profile. Please selectAfrican American or BlackAmerican Indian/Alaskan NativeAsianCaucasian or WhiteMultiracialNative Hawaiian/Pacific IslanderOtherWhat interests does the person you are contacting us about have?This helps us plan programming of interest to our communityWhat is your professional background?This helps us plan networking events for our communityWould you like to receive periodic postal mail from AANE?If this question is left blank you will receive postal mail from AANE.Yes No CAPTCHA