Page 2 of 3

All fields marked with * are required.

*Does your child have a diagnosis of autism?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

Please upload your diagnosis report.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Do you allow us to contact the psychologist/physician?
Yes
No

*Has your child ever received a psychological exam?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

Please upload the psychological exam.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Do you allow us to contact the psychologist/physician?
Yes
No

Page 3 of 3

All fields marked with * are required.

Primary Medical Insurance Company

Member ID or Policy Number

Group Number

Policy Holder Name

Policy Holder DOB

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Second Insurance Company

Member ID or Policy Number

Group Number

Policy Holder DOB

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Please upload the front and back of your insurance card

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your diagnosis report if you have one

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your Diagnostic evaluation/report (completed by a doctorate level clinician,Diagnosis date and by whom)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your MD prescription or signed coordination of care letter within the last 6 months

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

[NOTE: Ordering physician information such as address, name, tax ID and phone number.]

Please upload any reports such as IEP, Speech, or ABA that you may have.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.