Service Request / Referral Form

Service Request / Referral Form
* Our Family Services Coordinator will contact you within 3 business days.

* Submission of this form does not guarantee acceptance of the case, as it is based on availability matching.
Information
Date
Child's Name*

First NameLast Name
Child's Age*
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
example@example.com
Your Town / City in CT*
What insurance carrier does your child have? (i.e. Anthem, Medicaid, etc)*
Does your child have a formal Autism Spectrum Disorder diagnosis provided by a licensed professional (i.e. PhD, MD, LCSW, etc)?

YesNo
If you answer "No" to the above question, would you be interested in Autism evaluation for the purposes of diagnosis and treatment?

YesNo
Please list your child's availability. For children who have not yet started kindergarten, treatment can only be provided between 8:30am to 3:30pm.*
Message to our team:
Are you submitting a referral?

Yes - please answer the question below. Thank you.
If you are submitting a referral, please list your name, phone number and agency you are with. We will update you about the progress.
Please verify that you are not a robot*
Should be Empty:

Information