GHC-SCW Autism Spectrum Disorder Referral for Treatment

This form must be completed by a provider. Self-referrals will not be accepted. Please provide all of the required information. Missing information may result in delayed processing of this form. We may contact you or the patient directly for additional information. Please notify the patient of this referral. A separate referral must be filled out for each service.

Note: Some services have specific eligibility criteria. Please review the program descriptions below before selecting.

Our Current Programs:

Social Skills Development: Our evidenced-based program uses ecologically valid social skills to support children aged 4 to 16 in building friendships and managing social conflict and rejection. The program is a weekly intervention and includes parent/caregiver involvement in one-to-one or group settings.

Emotion Regulation Support: Treatment focuses on teaching strategies to help children aged 6 to 16 better understand and manage their emotions, particularly anger and anxiety. Programs include one-to-one support and group therapy, vary in length and include parent/caregiver involvement.

Occupational Therapy: The goals of treatment include enhancing sensory processing, fine motor skills and daily living abilities. These services are offered to children ages 3 to 18. Frequency and length of services vary.

Speech Language Therapy: Treatment focuses on supporting communication, language development and social-pragmatic skills. These services are offered to children ages 3 to 18. Frequency and length of services vary.

1. Select the service you are referring for*

Social Skills DevelopmentEmotion Regulation SupportSpeech TherapyOccupational Therapy

Speech Therapy - Please select goal area(s) of interest below:*

Expressive and receptive languageArticulation, phonology and speech claritySocial communication (pragmatics)AAC (augmentative and alternative communication) support

Occupational Therapy - Please select goal area(s) of interest below:*

2. Eligability Questions

Does the child have a have a verified medical diagnosis of Autism Spectrum Disorder (ASD)?*

YesNo

Does the patient have GHC-SCW commercial insurance?*

YesNo

If the patient does not have GHC-SCW commercial insurance, what insurance does the patient have? *

Is the child between the ages of 4 to 16 years old?*

YesNo

Is the child's primary residence in Dane County?

YesNo

Can the child communicate using full sentences (spoken, AAC, Sign Language)?*

YesNo

Does the child have any history of violence/aggression/property destruction?*

YesNo

Is this child over the age of 10 AND has shown violence/aggression/property destruction (e.g., an event that has resulted in significant injury to themselves or other, resulted in law enforcement involvement or significant property damage) in the last 3 months?*

YesNo

The referral cannot be accepted.

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-SCW 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-SCW HIM at 608-221-2646