Form – Autism Specific Services | Access Family Services

Instructions
Please complete the following information & submit online. You can also download this form from our website, fill out on your computer and print, scan and email to autismservices@accessfamilyservices.xyz, or print and fax to 919-896-6443.

* indicates required.
Date
Referred By: *
Referral Agency Phone Number: *

Last Name: *
First Name: *
Middle Initial: *
Email
DOB
Home Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Sex
MF
Race: (Optional)
SSN:
County

Parent or Legal Guardian Contact 1: *Name
Relationship to Client:
Mobile Phone:
Home Phone:
Email
Address (if different from client):
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Primary Language:
Parent or Legal Guardian Contact 2: Name
Relationship to Client:
Mobile Phone:
Home Phone:
Email Address:
Address (if different from client):
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Primary Language:

During the intake process we will be requesting detailed information regarding your child’s history, current needs, and caregiver concerns. Please identify your top three concerns that you would like addressed during the first 6 months of treatment.
1.
2.
3.
You will be hearing from us within 72 hours. At that time a member of Access Family Services will be requesting a copy of a signed diagnostic or psychological evaluation confirming a diagnosis of Autism Spectrum Disorder(F84.0).
Select Your Preferred Location:

Form – Autism Specific Services