Diagnostics Inquiry Form

How old is your child?
Your State
Which area of North Carolina?
Which Area of Virginia?
Your child is a little young for our evaluation, which starts at 18 months. If you have concerns now, please share them with your pediatrician; early conversations matter. If you have questions in the meantime, please call us using the phone number at the top of this page.
We currently offer diagnostic evaluations for children 18 months through 4 years. For a child who is 5 or older, your pediatrician can refer you to the right evaluation. If you'd like to talk it through, please call us using the phone number at the top of this page.
Our diagnostic evaluations are not currently available in your area. We encourage you to discuss your needs and concerns with your child's pediatrician who can help connect you with the right diagnostic provider.
Parent/Guardian Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child Name

First NameLast Name
Child's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit year
How did you hear about us?
Is there anything else you'd like us to know?
Security check
gclid
gbraid
wbraid
Has your child been diagnosed with autism spectrum disorder?
Insurance Subscriber ID
Insurance Group #
Should be Empty: