Autism Assessment
This evaluation includes an intake interview, administration and scoring of the Autism Diagnostic Observation Schedule (ADOS), Second Edition; Vineland Adaptive Behavior Scales, Third Edition; and a comprehensive written clinical report. You will receive a clinical report to provide to your primary care provider for consideration and signature if they agree with the findings, which may then be used to obtain an official diagnosis. Insurance is not billed for this service. The fee for testing is $500, due in full on the day of the appointment. If you are scheduling evaluations for more than one child, please complete a separate form for each child.
Parent or Guardian Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Name
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First Name
Last Name
Child's Date of Birth
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Month
-
Day
Year
Date
Primary concerns or reasons for seeking this assessment:
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Intake (1 hour)
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Assessment (2 hours and must be scheduled for a different day than the intake)
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Initial: I understand that this assessment will take place over two sessions — a one-hour intake and a two-hour assessment — scheduled at least one day apart.
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Initial: I understand that Anniston Academy does not bill insurance for this service.
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Initial: I understand the assessment cost is $500. I understand payment is required on the day of service before the evaluation begins.
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Initial: I understand that failure to attend the appointment or provide notice will result in a cancellation fee. I understand that I must cancel at least 24 hours in advance to avoid this fee.
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Initial: I understand I will be charged a $100 non-refundable deposit to hold my appointment that will be applied to the balance of the assessment cost.
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Initial: I understand that this assessment is for evaluation and informational purposes only and is not connected in any way to enrolling my child or to the admissions process at Anniston Academy.
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Autism Assessment - Deposit
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Final Acknowledgment & Signature: I understand this appointment includes an intake interview, developmental test administration, scoring, and a clinical report. I understand I will receive a clinical report to take to my child’s primary care provider for consideration to obtain an official diagnosis, should the provider agree with the findings. I agree to attend the scheduled appointments and understand that failure to show or cancel within the required timeframe may result in additional fees.
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Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
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