SCHEDULE A CONSULTATION Please fill out the fields below to submit an inquiry or service request to us electronically. Within 24 hours, we will review your information and get in contact to discuss how we can help. * denotes a required field First Name * Last Name * Date Of Birth: * Parent's Name: * First Name * Last Name * Email * Phone * Address Street * City * State/Province * Zip Code * Country * Preferred Method of Contact: --None-- Phone Email Geographical Area: * --None-- Altamonte Springs & Surrounding Areas Bradenton & Surrounding Areas Gainesville & Surrounding Areas Jacksonville and Surrounding Areas Ocala & Surrounding Areas Orange City & Surrounding Areas Orlando & Surrounding Areas Ormond Beach Palm Coast and Surrounding Areas Port Orange & Surrounding Areas St. Pete & Surrounding Areas Tampa & Surrounding Areas Wesley Chapel & Surrounding Areas Palm Harbor & Surrounding Areas Clearwater & Surrounding Areas Other (Please Describe in Comments) Diagnosis Select your child's diagnosis or (if multiple) diagnosis. Does your child currently have an autism diagnosis? * --None-- No Yes If no autism diagnosis, please list the relevant diagnoses: Has your child had a Comprehensive Diagnostic Evaluation completed? --None-- Yes No Unknown / Not Applicable If yes, does the Comprehensive Diagnostic Evaluation include an ADOS, CARS or other structured assessment? --None-- Yes No Unknown / Not Applicable If yes, please Provide the Name of the Provider and / or Their Practice That Conducted the Evaluation: If yes, in What Year Was the Evaluation Completed? (Approximate Is OK.) Who Is Your Insurance Carrier? * --None-- Aetna AvMed Blue Cross - All Plans Cigna Florida Kidcare (Wellcare Title 21) Humana Medicaid (Including Managed Care Plans) None (Private Pay) Other (Please Describe in Comments) Tricare United Unknown If your insurer is not listed, don't worry: we can still help. Please let us know of your carrier in the comments. Subscriber Name: Subscriber DOB: Policy Number: Group Number: How did you hear about us? * --None-- Google Primary Doctor Specialist (e.g. Developmental Psychologist) Client Referral Community Event Facebook Other (please describe in comments) Additional Comments: By submitting this form, you agree to receive text message communications from us. These messages will solely be used to contact you about your consultation request, and will not include any general marketing information. If you have any questions or would like to opt out of communication, please contact info@bassautism.com. Check here to agree. * Read now! TAKE A LOOK Read now! TAKE A LOOK
