Referral Form

Referral Date:
Date Format: MM slash DD slash YYYY
Parent/Guardian Information
Your Name:*
Email:*
Phone Number:
Home Address:
Information about the child referred to the Carmen B. Pingree Center
Address (if different from above):
Full Name:*
Date of Birth:
Date Format: MM slash DD slash YYYY
Age:
Gender:
Diagnoses:
Medical Conditions and/or Allergies:
Medications:
Medicaid
- Yes
- No
DSPD
- Yes
- No
Private Insurance (Name of Plan):
Any Other Funding:
Description of Adult
Description of the child with autism (approximate level of functioning in terms of cognitive, language, and self-help skills development- previous and current treatments or interventions being provided, anything else you wish to share about your child):
Describe areas of need that you would like to be goals of treatment:
Describe strengths:
Describe any behaviors (i.e. aggression, noncompliance, self-injurious, tantrums):

Parent/Guardian Information