Intake Forms Please Fill Out All Fields Please enable JavaScript in your browser to complete this form.Child's Name *Date Of Birth *Physical Address *Phone Number *Parent/Guardian Name *Parent/Guardian Email *Insurance Name *Insurance ID *Referring Physician Name *Physician Phone *Autism Diagnosis ?YesNoOther Diagnoses, list here: Behaviors of Concern *Doctor Referral Upload (PDF files only) Click or drag a file to this area to upload. Comprehensive Diagnostic Evaluation (PDF files only) Click or drag a file to this area to upload. Front of Insurance Card (PDF files only) Click or drag a file to this area to upload. Back of Insurance Card (PDF files only) Click or drag a file to this area to upload. Behaviors Occur Mainly (select one) *In the Community HomeSchoolInterested in Services at (select one) *Clinic HomeSchoolCommunityCommentSubmit Now