About - Autism Clinic

Your Name*

Contact Email*

Contact Phone Number*

What are you requesting?

Information about the clinic

Services for my child

An internship at the clinic

Other (The clinic does not offer diagnostic services.)

If other, please specify

If you are interested in services for your child:

How old is your child? We currently offer services to children ages 2 up to 7 years old.

Does your child have an Autism diagnosis report in place?

Yes

No

Name of insurance that covers ABA services

Requested Service Location

Home (While parents are not required to participate in the session itself, we do ask that a parent or guardian is present at home during the whole duration of the session. This is required for safety and liability purposes, to ensure a secure environment for the child and staff.)

Community Setting (Private school, Play Do Learn, etc.)

After School Sessions

Clinic (Currently unavailable-if you'd like to be added to the waitlist, please indicate.)

Home Address:if you selected home fill out address:

Community Setting If selected please specify:

After school sessionsIf selected please specify:

Requested days/times for services

Do you have any additional questions about the UofM Autism Clinic and our services? The clinic does not offer diagnosis services.

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Autism Clinic

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Autism Clinic

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