Autism Services Application

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 Info
Child's First Name*
Child's Middle Name
Child's Last Name*
Child's DOB*
MM slash DD slash YYYY
Child's Age in Months
Male/Female
- Male
- Female
Parent/Guardian #1 Info
Parent'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 State ZIP Code
Parent/Guardian #2 Info
Parent'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 State ZIP Code
What is the best time/way to reach you?*
What is the family's primary language?
Ethnicity
Race (choose all that apply)
Do 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?
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