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 Name
Last Name
Parent's/Guardian's Email Address:
*
example@example.com
Parent's/Guardian's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Client's/Child's Name:
*
First Name
Last Name
Child's Gender
*
Male
Female
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
City
State / Province
Postal / Zip Code
Preferred Partner
*
Please Select
As You Are (virtual)
Georgia Autism Center (in-person)
Glow Pediatrics (virtual)
Magnolia Wellness & Psychology (in-person or virtual)
Minder Memory (virtual)
Primary Insurance
*
Please Select
GA Medicaid
Aetna
Amerigroup
Anthem BCBS/Evernorth
CareSource
Cigna
Magellan
Peach State
Optum
Tricare East
United Healthcare
Front of Primary Insurance Card
*
Back of Primary Insurance Card
*
Secondary Insurance
Please Select
GA Medicaid
Aetna
Amerigroup
Anthem BCBS/Evernorth
CareSource
Cigna
Magellan
Peach State
Optum
Tricare East
United Healthcare
Front of Secondary Insurance Card
Back of Secndary Insurance Card
IEP or IFSP (if applicable)
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Other Reports (e.g., speech therapy, occupational therapy, medical etc.) (optional)
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