New Referral

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Selected Service:

Standard Private Pay Child Neurodiversity Assessment

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I will continue and want to create a new account.

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Are the services requested related to any civil or criminal proceedings?

Yes

We are unable to take on this request.

Are you filling this out for yourself or for a minor whom you have legal authority?

Yes

Please note that you must be the legal parent or guardian for this person and/or have legal authority to authorize delivery of services. If this person is an adult they must fill out this form on their own behalf.

The person requesting services must be an adult submitting this request on their own behalf or on behalf of a minor who they have legal authority to authorize delivery of services.