Welcome

1
Who is this autism evaluation for?* This field is required.
For me (an adult)For my child / dependent
2
What’s the patient full name?* This field is required.If you’re filling this out for your child, please enter your child’s name.
First Name
Last Name
3
Do you have the legal authority to make healthcare decisions for this dependent?* This field is required.
YESNO
4
What is the patient's verbal level?
Fully verbal
Fully verbal
Fully verbal
Fully verbal
5
Please share your phone number* This field is required.By sharing your phone number, you agree to receive texts from Arxohealth LLC and our affiliates. Standard message and data rates may apply.
Please enter a valid phone number.
6
Please provide your email address* This field is required.
example@example.com
7
Is the patient currently on a waitlist for care? If so, approximately how long?This helps us understand your current situation and plan accordingly.
Not on wailist
Yes, 1-6 months
Yes, 6-12 months
Yes, 12-18 months
Yes, 18+ months
8
Please tell us the state the patient is located in.If you are the patient, what state are you located in?
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
9
We accept most major commercial plans (BCBS, Anthem, Cigna, Aetna, UHC/Optum, Oscar). Don’t have insurance? No worries - we offer self-pay options and flexible payment plans.Choose the option that works best for you: *Let’s continue!* – Share your preferred payment method, and we’ll call you within 24–48 hours with an estimated coverage amount to help schedule your appointment. If you have insurance, please have your card handy. *Schedule a call to learn more* – Chat with our Care Concierge to get more details before proceeding.
YESNO
10
Which health insurance the patient will use, or will this be a self-pay appointment?Selecting your insurance helps us provide an accurate estimate and schedule your appointment efficiently.
Blue Cross Blue Shield
United Healthcare
Cigna
Aetna
Oscar
State Medicaid Plan or Medicaid plan administered by any of the above (example: BCBS Medicaid)
11
We’re unable to accept Medicaid at this time. Would you like to explore our self-pay option of $1,500? Flexible payment plans are available.* This field is required.
YESNO
12
Please upload a photo of the FRONT of your insurance card.To help us process your appointment quickly, please upload a clear photo of the front of your insurance card. We’ll request the back in the next step.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
Please upload a photo of the BACK of your insurance card.To help us process your appointment quickly, please upload a clear photo of the back of your insurance card. We’ll request the back in the next step.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
If you are the patient, please provide your date of birth* This field is required.To help us prepare for your appointment and verify benefits, please share the patient’s date of birth.
Date
Year
Month
Day
15
Please provide the patient's address.If you are the patient, please provide your address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Book a free consultation today with ArxoHealth Services* This field is required.
17
Is there anything else you’d like us to know?
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