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In-Take Form
Child's Full Name
*
Child's Date of Birth
*
Child's Health Insurance: Please include Secondary if applicable
*
Insurance ID Number
*
Parent/Guardian's Name
*
Address
*
Phone
*
Email
*
Does your child have Any Medical Conditions that they are being treated for by a physician (i.e. epilepsy)?
Yes
No
Other
Does your child need Speech and/or Occupational Therapy?
*
Yes
No
Does your child attend Daycare/Preschool, or Elementary School?
*
Yes
No
Preschool or Elementary School Name. Please include the times your child attends
*
Does the child have an ASD diagnosis? If so, do you have the ASD report?
*
No
Yes, and I have the ASD report
Yes but I don't have the ASD report
Upload Diagnostic Report
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Do you require Translation Services?
*
Yes
No
PCP Name & Number
*
Multi choice
*
I declare that the info I provided is accurate and complete
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ABOUT US
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AUTISM 101
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