Please answer question on FLASH Intake form.
The following information is used to create your child’smedical record and coordinate your remote autism diagnostic appointments.
Name of child?
Date of birth for child?
Preferred nick name?
Name of legal guardian of child ?
Phone of legal guardian?
Please enter a valid phone number.
Email of legal guardian?
Address of legal guardian?
Do you prefer correspondence in English or Spanish?
What is the reason for requesting this FLASH autism assessment?
Information about child :
Name and address of doctor who you give consent for sending the final report of FLASH autism assessment?
How did you locate our service?
Do You Have Reliable Internet Service with web camera capability?
Select date and time of your virtual visit.
( X )
All 4 appointments with discount
The payment is ready! It will be completed once you submit the form.
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