Referrals 2017-11-03T03:33:03+00:00

Please fill out the form 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.

In addition to clinic services, note that we currently serve the following areas onsite:
Northwest Fairfax County (north of I-66) and Loudoun County

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Child's Date of Birth (required)

Parent Name #1 (required)

Parent Name #2

Street Address (required)

City (required)

State (required)

Zip (required)

Mobile Phone

Home Phone

Work Phone

Who referred you to our services (name of doctor, agency, etc.)?

Reason for seeking services

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

What is the name of your child's school?

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 to access our services? (Required)

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

Are the child’s parents married to each other?
YesNo

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.

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.

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RECENT DEVELOPMENTS

Given the unprecedented number of recent emergency events, we compiled a set of resources for families and first responders to increase safety for those with special needs.  We hope you will find it helpful. Click [...]

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.