Diagnostic Evaluation Request

Diagnostic Evaluation Request Form
* Our Program 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 evaluator's availability.
Information
Date
Child/Client Name*

First NameLast Name
Child/Client's Age*
Client or Parent's Name*

First NameLast Name
Client or Parent's Phone Number*

Area CodePhone Number
Client or 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?*

Fall 2025- TBD (Next Availability)
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