Autism Herndon VA | Autism Consulting Fairfax VA

Please fill out the form below for new referrals. If the child’s parents are unmarried or divorced, we are required to know the legal guardian(s). You may also fax the form to us. Click here to download the form in PDF format and fax it to us at 571.333.0292. Click here to download form in Microsoft Word and email to us.

Patient Name	Patient Date of Birth

Parent Name

Street Address

City	State	Zip

Home Phone:	Mobile Phone

Work Phone:	Email Address:

Referred By:

Reason for seeking services:

Is your child in school? If so, list type of program (noncategorical special education, mainstream, autism classroom, etc.)?

Are you seeking a home based ABA program or more home/school coordination or evaluation of learning needs/placement?

Are there any specific behavioral concerns (tantrums, self injury, toileting difficulties, feeding issues, transitions, outings, social skills, etc.)?

If problem behaviors exist, what is being done now to address them?

Do you require any special accommodations for services?

Who does your child reside with (e.g., both parents, mother only, father only, etc.)?

If the child’s parents are unmarried or divorced, we are required to know the legal guardian(s). Please specify joint custody, sole custody, etc. We will require a copy of the legal custody documents to begin services and contact the other parent in joint custody cases for joint participation. Please indicate N/A as needed.


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