Autism Assessment Scheduling Form
Please note: there are 2 January dates for the first part of the assessment and 2 February dates for the second part of the assessment. These dates are the only offered dates at this time to ensure that everyone can receive their evaluations in a reasonable amount of time. Your child only has to be present for one of the assessments.
Client Name
*
First Name
Last Name
Client’s DOB
*
-
Month
-
Day
Year
Date
Parent/ Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Please make sure this is accurate - paperwork will be sent here!)
*
example@example.com
The name and contact information for your child's pediatrician (practice location is important):
*
Please choose your preferred time & date for ADI-R (parent interview for child’s developmental information- can be telehealth):
*
Please choose your preferred time & date for ADOS-2 (Child’s assessment- must be in person at 1719 Ashley Circle):
*
How do you plan to pay for the assessment?
*
Medicaid Insurance
Self-Pay
If you have insurance that you want to use, please tell us what insurance, and your member or Medicaid ID:
Submit
Should be Empty: