Autism Clinic Intake Form
Parent/Guardian Name
*
First Name
Last Name
Email
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best days and times to contact you
*
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
County You Live In
*
Please Select
Adams
Brown
Cass
Greene
Hancock
Knox
McDonough
Morgan
Pike
Schuyler
Scott
Warren
Other
Reason for Referral
*
Assessment Request
Consultation Request
Assesment Request
*
Please Select
I have a child under age 8 that I need to request a psychoeducational evaluation
I have a child older than age 8, but I still have assessment-related concerns
I have assessment concerns, but they are only related to speech-language needs
Consultation Request
*
Please Select
Consultation/question about school-based services
Consultation/question about behavior or adaptive skill needs
Consultation/question about sensory or communication concerns
Other, please specify
Specify reason for referral
*
Please let us know if you have any questions.
Submit
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