ASD Diagnostic Evaluation Interest Form

ASD Diagnostic Evaluation

Interest Form
Kind Behavioral Health is dedicated to supporting families on their journey with Autism Spectrum Disorder (ASD). We understand the challenges parents face in securing timely ASD evaluations for their children. To address this, we've connected with diagnostic specialists outside of our organization to bridge the gap between recognizing the need for an evaluation and obtaining an appointment.

These organizations are in alignment with our mission to enhance accessibility to diagnostic services. They are committed to broadening the availability of these essential services to meet the needs of our community.

To assist you effectively, the form below is designed to guide you to the diagnostic pathway that aligns with your specific requirements.

Please submit the basic information below, and based on your responses, we will direct you to the most suitable evaluation option for your needs.

Thank you!
Parent / Guardian Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please select your City and State*
Parent / Guardian Phone Number
Please enter a valid phone number.
Parent / Guardian Email*
example@example.com
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your relationship to the child?
What type of ASD Diagnostic Evaluation appointment is preferred?

In-person evalution (NC only)Virtual (Telehealth) evaluation
Closest Kind Behavioral Health clinic location*
How did you hear about KBH?
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