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

Interpreter Needed?

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?