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


    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?

    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.


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

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

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    We are excited to be restarting our social skills groups in our clinic, with careful restrictions!  Click here to check out this research article supporting how we run our groups.


    Once thought to be very rare, autism spectrum disorders are now estimated to occur in one out of every 59 individuals.  Click here for Autism Treatment »

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

    See for more information.