Diagnostic Inquiry Form

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Please complete this form to schedule a diagnostic assessment
A member of our team will call to confirm the appointment

Name of person completing this form *

Email *

Phone Number *

Name of Child *

Child's Date of Birth *

Insurance Carrier *

Policy Holder Name and Date of Birth *

Policy Number / Member ID *

Do you authorize Link to Learn Behavior Therapy LLC to verify insurance coverage for assessment purposes? *

Yes

How would you categorize your child's language skills? *

Pre-verbal - Single Words

Simple Phrase Speech (repeats same phrases)

Flexible Phrase Speech (3 - 4 word varied phrases)

Verbally Fluent (uses complex sentences)

Required

Does your child have any food restrictions or food allergies? *

Assessments Requested *

ADOS - 2

Vineland / Vineland Adaptive Behavior Scales

Complete Diagnostic Evaluation (administered by psychologist)

Other:

Required

Preferred Day of the Week for Assessment *

Monday

Wednesday

Friday

Saturday

Preferred Time of Day *

Morning

Afternoon

Evening

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