Please complete this form to request a new client appointment with Avenues for Autism. Once we receive your completed form, we will contact your insurance carrier to determine whether we are an in-network or out-of-network provider. Within 3-5 days, you will be contacted via email with instructions on how to schedule your appointment.

• For minor clients (under the age of 18), this form must be completed by a parent/legal guardian.
• For adult clients (18+) not under guardianship, this form must be completed by the individual (assistance may be provided as requested by the client)
• For adult clients under legal guardianship, this form must be completed by the legal guardian.

 

If you have any difficulties with this form, please contact the Avenues for Autism Main Line at (419) 210-5095.

Please identify an emergency contact. This does not give Avenues for Autism permission to discuss details relating to your treatment with this individual. This information is only used if a medical or behavioral health emergency arises during a session.