Prospective Client Name *

First Name

Last Name

Parent/ Caregiver Name (if applicable)

First Name

Last Name

Phone

(###)

###

####

What Services Are You Interested In? *

Individual Therapy/ Counseling/ Support

Evaluation/ Testing/ Diagnosis

Groups/ Workshops (Click to see options)

Medication

Autism Transition-to-Adulthood Consultation

Unsure/ Other

Please review and acknowledge the disclaimers below before submitting *

We respect your privacy and take steps to protect it whenever possible, but please understand that electronic communication, including web forms and email, can still be intercepted by a third party.

Submitting this form does NOT create a therapeutic relationship.

You will NOT receive a copy of this form. If you would like to keep a record, please take a screenshot before submitting.

Submitting this form does NOT place you on a traditional waitlist or guarantee you will be offered services.