Autism Evaluation Application for Discover Autism

Autism Evaluation Application for Discover Autism

Please complete the following form to submit an application for an autism evaluation on behalf of your child.
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Caregiver/Parent 1 Name*

First NameLast Name
Caregiver/Parent 1 Email*
example@example.com
Caregiver/Parent 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Caregiver/Parent 2 Name (if applicable)

First NameLast Name
Caregiver/Parent 2 Email (if applicable)
example@example.com
Caregiver/Parent 2 Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Where is your child currently on a waitlist for a developmental evaluation and/or an evaluation for autism spectrum disorder?*
Who referred you to Discover Autism?*
YesNo
I,blank*,understand and acknowledge that Discover Autism is a tax-exempt organization focused on placing and funding autism diagnoses in case of need and does not render any medical or health care services, diagnostic or otherwise, of any kind.
Signature*
Should be Empty: