Please complete this form to refer a child for autism services. Our intake coordinator will call you to discuss your concerns and schedule an evaluation. Child InfoChild's First Name* Child's Middle Name Child's Last Name* Child's DOB* MM slash DD slash YYYY Child's Age in MonthsMale/Female Male Female Parent/Guardian #1 InfoParent's/Guardian's #1 First Name* Parent's/Guardian's #1 Last Name* Parent's/Guardian's #1 Email Address* Confirm Email Address Parent's/Guardian's #1 Home Number*Parent's/Guardian's #1 Cell Phone*Parent's/Guardian's #1 Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian #2 InfoParent's/Guardian's #2 First Name* Parent's/Guardian's #1 Last Name* Parent's/Guardian's #1 Email Address* Confirm Email Address Parent's/Guardian's #2 Home Number*Parent's/Guardian's #2 Cell Phone*Parent's/Guardian's #2 Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the best time/way to reach you?*What is the family's primary language? EthnicityHispanic or LatinoNot Hispanic or LatinoRace (choose all that apply)WhiteAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderDo you have health insurance? Yes No If yes, who is your insurance provider? How did you hear about Kids Who Count? Does your child have a diagnosis? If yes, what is the diagnosed condition?What concerns you about your child’s development?Anything else you'd like us to know before we contact you?CAPTCHA Δ adminAutism Services Application08.02.2018