Contact Us Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your Name: *FirstLastYour Email: * the child: Name: Age of your child: *Has your child received an official diagnosis for any of the following? *Austim Spectrum Disorder (ASD)Fetal Alchohol Syndrom (FAS)Attention-Deficit/Hyperactivity Disorder (ADHD)PicaHave you received an official diagnosing report?N/AYesNoOtherIf you are waiting for diagnosis, please select other and input the date scheduled to be diagnosed.Best Contact Phone Number: *Select the primary payment type (Insurance or Cash Pay): *Cash PayInsurance CompanyInsurance companies require an official diagnosis of ASD or FAS to allow for submittal of a prior authorization. When selecting a primary insurance company, please input the name of the insurance group.Select the Child's Secondary Insurance *N/AInsurance CompanyIf selecting a secondary insurance company, please input the name of the insurance group.Briefly Describe your Inquiry/Needs *Submit
