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
Format: (00) 00000000.
Parent 1 Name

First NameLast Name
Parent 2 Name

First NameLast Name
Paediatrician Name (if you have one)

First NameLast Name
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
YesNo
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
Yes - I will prepare all required paperwork as soon as possible to facilitate this
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Autism Assessment Waitlist