Registration Form

Autism Assessment Waitlist

Fill out the form carefully for consideration for an Autism assessment
Child's Name

First NameMiddle NameLast Name
Child's Birth Date

MonthDayYear
Child's Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent E-mail
example@example.com
Parent Mobile Number
Parent 1 Name

First NameLast Name
Parent 2 Name

First NameLast Name
Paediatrician Name (if you have one)

First NameLast Name
Please confirm if you have the appropriate legal authority to made health-related decisions for the child named in this form

Yes - full legal authorityYes - partial or shared legal authority and I understand the other legal guardian is entitled to accessing the information gathered during this processNo
Child's School or Daycare
Do you give permission to discuss information with the teacher and/or other relevant education staff?

YesNo
Please indicate which type of autism assessment you need

Multidisciplinary assessment with speech pathologist and psychologist (most common option)Speech pathologist only - another psychologist has done the assessmentPsychologist only - another speech pathologist has done the assesssment
There is currently a 4-6 month waitlist for autism assessments. Please tick this box below if you wish to be contacted in case we get a last minute cancellation:

Yes - I will prepare all required paperwork as soon as possible to facilitate this
Please sign

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I understand the full cost of the assessment ($3000) will be due immediately following my appointment in the clinic. A $500 deposit will be due 4 week prior to the assessment and failure to pay will terminate the service.*

Yes
Should be Empty:

Autism Assessment Waitlist