Get Started With Your Child’s Autism Evaluation
You’re in the right place. Complete the form below to connect with our team through the Autism Hero Project partnership. We’ll reach out within one business day to answer your questions and help you schedule your child’s autism evaluation.
Parent/Caregiver Name:
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Child Name:
*
First Name
Last Name
Child's Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Diagnosis of Autism
What zip code do you reside in:
*
We will use this zip code for scheduling location purposes.
How did you hear about us:
*
Please Select
Autism Hero Project
Pediatrician / Physician
Therapist (Speech / OT / PT)
School or Early Intervention
Friend or Family Member
Facebook / Social Media
Google Search
Community Event
Insurance Provider
Other
Name of Pediatrician or Clinic that referred you:
Name of Community Event:
Insurance Name:
*
Please Select
Aetna
Anthem
Blue Cross Blue Shield
Cigna
United
Medicaid
UMR
Other
No Insurance
For Blue Cross Blue Shield, what type of plan is it?
PPO / Commercial
HMO / Commercial
Medicaid (BCBS Community)
Not sure/Other
Funding Type- Private
Funding Type- Medicaid
Funding Type- No Insurance
Funding Type- Both
*
Funding Type-
*
For Aetna, what type of plan is it?
PPO / Commercial
HMO / Commercial
Medicaid (Aetna Better Health)
Not sure/Other
For Medicaid, do you also have a Private Insurance Plan:
Yes
No, only medicaid
Not sure/Other
Program of Interest
Referral Source
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Submit
Should be Empty: