Referrals 2017-04-22T14:32:33+00:00

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 fill out the form and submit it or you may download the form and bring it with you when you visit our office.  Click here to download the form in PDF format. Click here to download form in Microsoft Word and email to us.

SSL site seal - click to verify

Note that we currently serve the following areas: Northwest Fairfax County (north of I-66) and Loudoun County

Patient Name (required)

Patient Date of Birth (required)

Parent Name (required)

Your Email (required)

Street Address (required)

City (required)

State (required)

Zip (required)

Mobile Phone

Home Phone

Work Phone

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.


Save

ABOUT US

Dr. Jane Barbin is one of the only doctoral level autism experts in the surrounding area.  Read More…

Goals for Treating Autism. You are not alone. We can help.

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List iconSign up for our Email Newsletter

RECENT DEVELOPMENTS

Is My Child’s BIP Working? By: Dr. Jane Barbin, PhD, BCBA-D, LBA In our recent newsletters, we have explored the meaning and process for conducting a Functional Behavioral Assessment and creating the very best [...]

AUTISM TREATMENT

Once thought to be very rare, autism spectrum disorders are estimated to occur in an many as 1: 66 (one in every 66 people). Click here for Autism Treatment.

Did you know ASAT provides accurate, science-based information and promotes access to effective autism treatment?

See www.asatonline.org for more information.