ASD Evaluation Appointment Request

ASD Evaluation Assessment Appointment Request

In order for us to submit a request for an ASD evaluation appointment to one of our partners on your behalf, please provide the following information below:
Parent/Guardian's Name:*

First NameLast Name
Parent's/Guardian's Email Address:*
example@example.com
Parent's/Guardian's Phone Number:*
Please enter a valid phone number.
Alternative Phone Number:
Please enter a valid phone number.
Client's/Child's Name:*

First NameLast Name
Child's Gender*

MaleFemale
Child's Birthdate:*
MM/DD/YYYY
Is your child under the age of 6 years?*

Yes, my child is under 6 years of age.No, my child is over the age of 6 years.
IMPORTANT NOTE: Although some of our partners diagnose teens and adults, some do not evaluate clients over the age of 10 years. Additionally, we are early interventionists and only provide clinic-based ABA therapy to clients below the age of 5 years 6 months. Therefore, we will not be able to collaborate on ABA services or provide in-clinic virtual evaluations for clients who are above this age range. However, they MAY still be seen for an evaluation by one of our partners in their offices or in your home. By typing "I understand" you are acknowledging you have read this statement. *
Child's Doctor/Pediatrician:
Child's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Partner*
Primary Insurance *
Front of Primary Insurance Card*
Back of Primary Insurance Card*
Secondary Insurance
Front of Secondary Insurance Card
Back of Secndary Insurance Card
IEP or IFSP (if applicable)

Cancelof
Other Reports (e.g., speech therapy, occupational therapy, medical etc.) (optional)

Cancelof
Should be Empty:

ASD Evaluation Assessment Appointment Request