Referrals

  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian Information

  • Information about the child referred to the Carmen B. Pingree Center

  • Date Format: MM slash DD slash YYYY
  • 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):