GHC-SCW Autism Spectrum Disorder Referral for Diagnosis

Please be advised that we do not conduct assessments for learning disabilities.
Patient's Legal Name

First NameLast Name
Patient's Chosen Name, if Other than Legal Name
Patient's Pronouns
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?
Should be Empty: