Inclusive RACE Clinic Dr. Ferguson

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Rapid Autism Clinical Evaluation Clinic for children ages 18-47months conducted by Dr. Anjali Ferguson

*DISCLAIMER: A limited number of slots are available for the clinic. A waitlist will be created based on interest and families will be contacted after determining eligibility.

Email *

Today’s Date *

YYYY

Parent/Caregiver Name *

Parent/Caregiver Phone Contact *

Parent/Caregiver Email Contact *

Can we contact you by email for scheduling? *

Yes

Required

Residential Zip Code *

Child's Name *

Child's Age *

Child's Race/Ethnicity *

Black/African/African-American (non-Latinx/non-Hispanic)

Asian/Asian-American/Pacific Islander (non-Latinx/non-Hispanic)

White/European-American (non-Latinx/non-Hispanic)

Latino/Latinx/Hispanic

Native Hawaiian/Pacific Islander

Native-American/Alaska Native/Indigenous

Biracial

Multiracial/Multiethnic

Not Listed

Required

Was your child referred or recommended for a developmental evaluation by a teacher or pediatrician? *

Yes

Required

What is the name of the agency that referred you? Please specify location

What developmental concerns do you have for your child? *

What are your child's strengths? *

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