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.

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Date Of Birth: *

Parent's Name: *








Address











Preferred Method of Contact:

Geographical Area: *



Diagnosis

Select your child's diagnosis or (if multiple) diagnosis.

Does your child currently have an autism diagnosis? *

If no autism diagnosis, please list the relevant diagnoses:

Has your child had a Comprehensive Diagnostic Evaluation completed?

If yes, does the Comprehensive Diagnostic Evaluation include an ADOS, CARS or other structured assessment?

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? *

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? *

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. *

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