Get Started Today — Innovative Spectrum Services

Getting Started

We are here for you.

Thank you for taking the first step towards you or your loved ones goals. Please fill out this pre-screening form which we will use to gather more information to supplement our first session.

Name

Your name

First Name

Last Name

Relationship to Patient

What is your relationship to the person looking for services?

Patient's Name (If different from above)

Person's name who is receiving services (if different)

First Name

Last Name

Patient's Birthday

Birthday

YYYY

Email address

Phone number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical disgnosis

Has the patient received a medical diagnosis of autism?

If so...

If so, who was the qualified healthcare provider?

Date of diagnosis

Please list the date of diagnosis.

YYYY

Referring Provider/Entity

Primary Care Provider Name

Primary Insurance

Primary insurance (if none, put N/A)

Insurance ID

Section

How did you hear abour us?

How did you hear about us?

About

Reason for your visit

Briefly describe the reason for your visit.

Additional Details

What do you hope to accomplish with our services?

Improvement

What area's are in need of most improvement? (Daily routine? Outbursts?)

Last doctor contact

Please describe when the last doctor contact for this diagnosis was.

Current treatment

Is the patient currently receiving care for this diagnosis?

Getting Started

We are here for you.

Working together, we can make a difference.