Schedule an Appointment

Initial Placement Screening

We know you are busy!

Let us schedule your initial placement screening for your child. It is simple – just fill out the form below, answer a few questions, and send it in. Once we receive your request, we will email or call you with an appointment day and time!

Schedule an Appointment Adult Clients

Schedule Information

Please select a day and time you prefer. We will contact you with an appointment.
The best day for me is*
The best time is*
Adult Client Information
If you are over the age of 18, please complete the following information
Name*
First Last
Phone*
Date of Birth
MM slash DD slash YYYY
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I am interested in*
*Adult Clients Only: Please tell us your concerns
Referred by (please check one)*
- Doctor
- Family
- Friend
- Close to Home/Work
- Website
- School
- Other
If "Doctor", enter the doctor's name
If "Other", enter more information
I understand that there is an initial social communication assessment fee of $95.00 that is due at the time of service*

* Enter your initials
I would like to pay my $95 assessment fee now using my credit card*
- No
- Yes
Placement Fee
Price:
Total
$0.00
Credit Card*
Card Details
Cardholder Name
Email
This field is for validation purposes and should be left unchanged.

Schedule an Appointment

Schedule Information

Client Information- Pediatric ONLY (ages 2 1/2-17) *ADULT Clients, Please scroll to the form below for the Adult Intake Form

Child Information

Parent Information

Schedule an Appointment Adult Clients

Schedule Information

Adult Client Information

Schedule an Appointment

Schedule an Appointment

Schedule Information

Client Information- Pediatric ONLY (ages 2 1/2-17) *ADULT Clients, Please scroll to the form below for the Adult Intake Form

Child Information

Parent Information

Schedule an Appointment Adult Clients

Schedule Information

Adult Client Information

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