Autism Assessment Waitlist
Fill out the form carefully for consideration for an Autism assessment
Child's Name
First Name
Middle Name
Last Name
Child's Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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5
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Child's Gender
Please Select
Male
Female
N/A
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent E-mail
example@example.com
Parent Mobile Number
Parent 1 Name
First Name
Last Name
Parent 2 Name
First Name
Last Name
Paediatrician Name (if you have one)
First Name
Last 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 authority
Yes - partial or shared legal authority and I understand the other legal guardian is entitled to accessing the information gathered during this process
No
Child's School or Daycare
Do you give permission to discuss information with the teacher and/or other relevant education staff?
Yes
No
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 assessment
Psychologist only - another speech pathologist has done the assesssment
Please sign
I understand the full cost of the assessment ($2500) will be due immediately following my appointment in the clinic and failure to pay will terminate the service.
*
Yes
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