Language
English (US)
Submission Date
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Month
-
Day
Year
Date
Patient Information
Child's Age
*
Please Select
Under 1
1
2
3
4
5
6
7
8
9
10
Over 10
Select Your Location
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Alabama
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Maryland
Michigan
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Tennessee
Virginia
Select Your State
*
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Alabama
Georgia
Idaho
Illinois
Maryland
Michigan
Missouri
Oregon
Tennessee
Virginia
Does your child have a formal autism diagnosis?
*
Yes
No
In progress
Please provide the date your child's assessment is scheduled.
*
-
Month
-
Day
Year
Date
Insurance Type
*
Commercial
Medicaid
Tricare
Out of Pocket
Therapy Preference
*
Center-Based Therapy
In-Home Therapy
In-School Therapy
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Email
*
Preferred Method of Contact
*
Phone
Email
Text Message
Yes Option
Yes
No Option
No
Qualified Intake
Yes
No
Insurance Accepted
Yes
No
Jotform Fake Email
example@example.com
How did you hear about us?
Please Select
Google
Doctor Referral
Insurance Referral
Autism Resource Organization
State Early Intervention Program
Outside Provider (Speech, OT, PT)
School/Daycare Provider
Community Event
Friend/Family Member
Social Media (Facebook, Instagram, Podcast, etc.)
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