Early Interest Form – Suspecting Autism but Not Yet Diagnosed

If you're noticing signs or have concerns about your child's development, you're not alone.

We're here to support you — diagnosis or not — with guidance, care, and a place to start.

Parent/Guardian's Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Contact Number

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Developmental Concerns:

What behaviors, delays, or challenges have you noticed that led you to seek support?

Has your child received any prior developmental evaluations?

Yes

Are you currently working with a pediatrician, psychiatrist, or psychologist for diagnosis?

Yes

Looking for referral

If yes, provider's name and contact info (if known):

Insurance Information

Insurance Provider:

Member ID:

Primary Subscriber Name:

Take a minute to write an introduction that is short, sweet, and to the point.