Thank you for your interest! Please submit the intake form to expedite onboarding.

First name

Last name

Email

Phone

Location/address

Insurance company

Member Id

Does your child have a current psych-evaluation/autism diagnosis?

Yes

No

Is your child in school?

Yes

No

Does your child receive any other related services? (speech, OT, PT?)

Yes

No

School's name (put N/A if not applicable)

School schedule (put N/A if not applicable)

Psychological Evaluation

Upload any related documentation (up to 3 files)

Insurance Card

Upload any related documentation (up to 3 files)