Evaluation Request

Demographic Information
Child’s Date of Birth  
What services are you requesting?  Check all that apply
Connectivity  Do you have a reliable internet connection that would allow you to meet through a video call platform?

Custody Disputes  As our clinic is a training clinic for students, we are not the best option for families who are currently involved in custody disputes. Are there any current custody disputes in process for your child?

Intellectual Disability  Has your child been previously diagnosed or suspected to have an intellectual disability?

Neurological, Genetic, or Developmental Disorders  Has your child been previously diagnosed to have a neurological, genetic, or developmental disorder (e.g., Autism Spectrum Disorder, Down’s Syndrome, etc.)?

Could we contact you to provide information about research studies if your child is eligible to participate?