WHO IS ELIGIBLE FOR OUR SERVICES?

We serve children 2-18 years old with ASD (Autistic Spectrum Disorder) and other pervasive developmental disorders. Fill out the consultation request form below and we will contact you as soon as possible.

CONSULTATION REQUEST FORM

This form allows a potential client to submit their information for a consultation for services. It is not binding, but allows us to get the preliminary information we need, so we can best assist you during our intake process. All information provided is secure and will not be used for any purpose other than serving your family.

CHILD'S INFORMATION

First Name

Date of Birth

Last Name

Age

Diagnosis

PARENT'S OR LEGAL GUARDIAN'S INFORMATION:

Parent/Guardian:

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

State

Postal / Zip code

INSURANCE INFORMATION

First Name

Last Name

Policy Number

Group Number

Date Effective

D.O.B OF POLICY HOLDER

How did you hear about us?

Initials

Today's Date

I declare that the information I’ve provided is accurate and complete.

Thank you for contacting us, we will reach out to you shortly!