(786) 878-1331

team@childrenautismhelp.com

Schedule Appointment

team@childrenautismhelp.com (786) 878-1331

Appointment

Patient Intake. Step 1

Please fill out the form below, after that schedule your appointment using the calendar.

(ver el formulario en español)

Parent/Guardian Information

Parent 1 First Name*

Parent 1 Last Name*

Parent 2 First Name

Parent 2 Last Name

Individual Receiving Services

First Name*

Last Name*

Date of Birth*

Contact Details

Primary Email*

Primary Phone*

Secondary Email

Secondary Phone

Funding Source*

Address Information

Address Line 1*

Address Line 2

City*

State*

Zipcode*

Preferred Location

Preferred Location*

Interested in nearby location if preferred location is unavailable

Additional Information

Is your child currently diagnosed with Autism or a related disorder?

Yes

Seeking diagnosis

Program Preference:

Comprehensive program, typically 8-3pm M-F

Focused program, typically 3-6pm M-F

How did you hear about us?

Consent

I have read and agree to the Privacy Policy*

I consent to receive communications via phone, email, or text

Additional Notes