Have you been diagnosed with Autism or ADHD?* This field is required.

YESNO

Has a loved one or a professional suggested that you get tested for Autism?* This field is required.

YESNO

Do you have a hard time coping with stressors and act out when you're frustrated?* This field is required.

YESNO

Do you struggle communicating, getting along with others, or building relationships?* This field is required.

YESNO

Do you have difficulty with change, or struggle with rigid routines and inflexible thinking?* This field is required.

YESNO

It sounds like you would be a great fit for our Autism and Behavior program ✅

And we would love to chat with you.

After answering a few more questions here, you will be able to schedule a call with our Program Director, Chris Smith, where he can answer your questions and start building your personal growth plan.

You might not be a great candidate for our program, but we'd still love to talk with you.

Please click VIEW SCHEDULE to book a call with our team, and we'll connect you with the resources you need.

Are you interested in our Autism & Behavior program for yourself or on behalf of someone you care about?* This field is required.

Myself

Someone I care about

If you're comfortable, will you please share your age and preferred pronouns?

How old are you?

Which pronouns do you use?

Have you already received a specific diagnosis?* This field is required.

Yes

What is their name, and what is your relationship to them?* This field is required.

First Name

Last Name

Your relationship

What is {theirname[1]}'s age and their preferred pronouns?

Age

Preferred Pronouns

Have they already received a specific diagnosis?* This field is required.

Yes

What was the diagnosis?* This field is required.

What is your name, phone number, and email address? This is how Chris will contact you for your first call to see if you are a good candidate for our Austim & Behavior program.* This field is required.

What's your name

Please enter your phone

Please enter your email

When would you like to talk?

The next step is to select the time you'd like to talk with Chris Smith. Click VIEW SCHEDULE to pick the day and time that works best for you.

Lead Status* This field is required.

Contacted - awaiting follow up from patient.

Scheduled a consult

Patient Moving Forward - KAP

Patient Moving Forward - IM TRD

Patient Moving Forward - Spravato

Consult held - patient will get back to us

No showed consult - follow up text sent.

Therapy Referral?

YESNO

Provider (If Scheduled)

David Danish

Joe Gagnon

Kellie Booth

Jagruti Amin

Kevin Keane

Amber Donnelly

Alexa Gavrilov

Alane Esposti

Caroline Doran

Chris Smith

Dana Pound

David Feeney

Dominic DeAngelo

Jahlia Smallwood

John Guardiani

Juan Montoya

Justin Bwint

Justin Vespasiani

Kendra Prescott

Kianna Morgan

Kristen Ott

Laura Wann

Lauren Bartholomew

Maggie Coleman

Mark Agnew

Marni Mackey

Meghann Beringer

Rebecca Lichtenstein

Sophia Gant

Stephanie Dunn

Theresa DiSipio

Other

Admin Staff

Julia

Justin

Juan

Laura

Ruby

Alexa

Other

How did you hear about us?* This field is required.

Online search

Another health care provider

Friend/family member

Other

Reason for Lost Lead

Contacted x3 with no response

Looking for insurance based - referred to Alpine

Practice does not meet patient's clinical need

Spam/Marketing

Too Risky - referred for higher LOC

Other