GHC-SCW Autism Spectrum Disorder Referral for Diagnosis

Patient's Legal Name*

First NameLast Name

Patient's Chosen Name, if Other than Legal Name

Patient's Pronouns

Patient's Date of Birth*

Date

Medical Record or GHC Member Number

Patient's Insurance

YesNo

If Yes, Which Language?

Parent/Guardian*

First NameLast Name

Patient or Parent/Guardian Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Referring Provider*

Referring Provider Email*

example@example.com

Referring Provider Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Referring Provider Facility*

What diagnostic questions do you have for the patient (e.g., Autism Spectrum Disorder, Intellectual Disability)?*

As a reminder, we do no conduct assessments for learning disabilities.

Why are you referring this patient for an ASD assessment?

Patient records available via electronic medical recordsPatient records will be sent via fax to GHC HIM at 608-221-2646