Initial Autism ADHD Assessment Form

 Your Name 
 Your Email 
 Your Phone 
 Best time to call you 
    
 Child's Name 
 Child's Age 
 Child's Gender 
Male Female

 

Please describe any existing or previous diagnosis:

Please describe any existing or previous interventions or therapies:

Any other instructions, remarks or questions? (e.g. preferred dates and times)

Please enter the two words that you see below, or else you will get an error message.

*

* Initial Assessment fee will be waived if you sign up for our therapy services. Our staff will contact you to clarify any questions before we confirm the assessment appointment.

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