GHC-SCW Autism Spectrum Disorder Referral for Treatment

Please provide all required information. Missing information may result in delayed processing of this request. We may contact you or the patient directly for additional information. Please notify the patient of this appointment request.

Our Current Programs:

Social Skills Development: Our evidenced-based program uses ecologically valid social skills to encourage children aged 8 to 16 to build friendships and manage social conflict and rejection. The program is a 14-week, individual, home-based intervention and includes parent/caregiver involvement.

Emotion Regulation Support: Treatment focuses on teaching strategies to help children aged 6 and above with Austism Spectrum Disorder (ASD) better understand and manage their emotions, particularly anger and anxiety. The program is a 10-week, individual, home-based intervention and includes parent/caregiver involvement.

Does the child have a have a verified medical diagnosis of Autism Spectrum Disorder by a medical professional?

YesNo

Is the child between the ages of 6 - 16 years old?

YesNo

Does the patient have GHC-SCW insurance?

YesNo

Is the child's primary residence in Dane County?

YesNo

Can the child's communicate verbally using full sentences?

YesNo

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?

YesNo

If Yes, Which Language?

Parent/Guardian Name*

First NameLast Name

Patient or Parent/Guardian Phone Number*

Please enter a valid phone number.

Referring Provider*

Referring Provider Email*

example@example.com

Referring Provider Phone Number*

Please enter a valid phone number.

Referring Provider Facility*

What concerns do you have regarding social skills or emotional regulation? Please provide examples:*

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

Our Current Programs:

Thank you for completing this form. Based on the responses provided, the child does not meet the criteria of the ASD program.