Diagnostic Evaluation Request

Diagnostic Evaluation Request Form
* Our Family Services Coordinator will contact you within 3 business days.

* Submission of this form does not guarantee acceptance of the request, as it is based on the evaluators availability.
Information
Date
Child's Name*

First NameLast Name
Child's Age*
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
example@example.com
Your Town / City in CT*
Currently, our evaluator is only in-network with Medicaid. Please choose:*

MedicaidPrivate Pay
Do you prefer a virtual or in-person appointment?*

VirtualIn-Person
When are you available for an in-person evaluation?*

November 2024Summer 2024
If diagnosed, would you like your child to begin ABA Therapy if we have the availability?*

YesNo
Please list your child's availability for ABA therapy. For children who have not yet started kindergarten, treatment can only be provided between 8:30am to 3:30pm.*
Message to our team (ex: Reason you are for looking for an evaluation):
Are you submitting a referral?

Yes - please answer the question below. Thank you.
If you are submitting a referral, please list your name, phone number and agency you are with. We will update you about the progress.
How did you learn that we offer ASD diagnostic testing?
Please verify that you are not a robot*
Should be Empty:

Diagnostic Evaluation Request Form