Autism Diagnosis Group Pediatric Form

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Welcome to the Autism Diagnosis Group! Let's collect some information to get started.
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Is this autism evaluation for an adult or child / dependent?* This field is required.
For myself - an adultFor a child / dependent
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Many people being evaluated for autism also have symptoms of ADHD. Would you be interested in an ADHD evaluation in addition to an autism evaluation?
YESNO
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Do you have the legal authority / power of attorney to make healthcare decisions for this individual / child? * This field is required.
YESNO
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Please have the individual who has legal authority to make healthcare decisions for this individual / child complete the form. Thank you!
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What is the child / dependent's first and last name?
First Name
Last Name
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What is the child / dependent's verbal level?
Minimally/Non-verbal - capable of a few words at most
Partially verbal/Phrase speech - ability to use phrases, but not complete sentences
Fully verbal - capable of complete sentences
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What's your first and last name?* This field is required.
First Name
Last Name
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What's your phone number?* This field is required.By providing your phone number, you consent to receive texts from Autism Diagnosis Group NJ PC and affiliates. Msg & data rates may apply.
Please enter a valid phone number
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What's your email address?* This field is required.
example@example.com
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Is the patient currently on a waitlist? If so, how long?* This field is required.
Not on a waitlist
Yes, 1-6 months
Yes, 6-12 months
Yes, 12-18 months
Yes, 18+ months
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What state is the patient located in?* This field is required.If you are the patient, what state are you located in?
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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We accept most major commercial plans (BCBS, Anthem, Cigna, Aetna, UHC/Optum, Oscar). No insurance? No problem—we offer self-pay rates and flexible payment plans.* This field is required.Choose from the options below: Let's continue! - Share your preferred payment method and we will call you in 24-48 hours with your estimated coverage to schedule your appointment. If you have insurance, please have your insurance card ready! Schedule a call to learn more - Chat with our Care Concierge to get more information first
Let's continue!Schedule a call to learn more
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Choose the health insurance the patient will use or if payment is out of pocket?* This field is required.Blue Cross Blue Shield includes any BCBS associated plan (including Anthem, Independence, Horizon, CareFirst, etc.)
Blue Cross Blue Shield
United Healthcare
Cigna
Aetna
Oscar
State Medicaid Plan or Medicaid plan administered by any of the above (example: BCBS Medicaid)
Out of pocket (payment plans available!)
Other
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We unfortunately do not accept Medicaid at this time. Would you be open to our out of pocket option of $1,500 (payment plans available)?* This field is required.
YESNO
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Please upload a copy of the FRONT of your insurance card. Thanks!* This field is required.We will ask for a picture of the back next
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload a copy of the BACK of your insurance card. Thanks!* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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What is the patient's date of birth?* This field is required.If you are the patient, please provide your own date of birth. This is needed to verify your benefits and set the appropriate clinical protocol.
Date
Month
Day
Year
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Please provide the patient's address.If you are the patient, please provide your address
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Book a free consultation with an ADG Care Concierge!* This field is required.The doctor's office will be calling from 210-900-2123 or 210-900-2599. Please add these numbers to your contacts.
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How did you hear about us?* This field is required.
Google Search
Facebook
Referral from a friend
Referral from a therapy center, doctor's office, etc.
Other
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Please provide the name of the clinic, therapy center, or doctor that referred you.
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Is there anything else you'd like to share?OPTIONAL
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The doctor's office will be calling from 210-900-2123 or 210-900-2599. Unrecognized numbers can sometimes be screened as spam so please add these numbers to your contacts.
Okay
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Should be Empty: