Comprehensive Autism Evaluation Interest FormRequest an Evaluation PacketThank you for your interest in Comprehensive Autism Evaluations through the Tucson Alliance for Autism. Please complete the form below to request an evaluation packet. Once your completed packet is returned, our office will contact you regarding scheduling and deposit information.First NameLast NameEmail Address *Phone *Who is the evaluation for? *Child (under 18 years of age)Adult (18 years of age or older)Are there any custody agreements, court orders, or legal decision-making arrangements that we should be aware of regarding this child? *YesNoDate of birth of individual being evaluated: *Why are you requesting an autism evaluation? *How did you hear about us? *Friend/FamilyMedical Provider/CaseworkerSocial MediaGoogle/Search EngineOtherImportant Information & AcknowledgementsPlease review and acknowledge the following:TAFA provides Comprehensive Autism Evaluations at our center for children and adults. The evaluations are beneficial for confirming the actual diagnosis of Autism Spectrum Disorder (ASD) and for assisting in the treatment of individuals with ASD. Our evaluations assess current levels of symptoms, social awareness, and level of impairment. We utilize both the ADOS-2 and the ADI-R diagnostic tools, which are considered the gold standard to provide the most complete and comprehensive ASD evaluation.I understand that for evaluations involving a child under 18 years of age, at least one parent or guardian must participate in the ADI-R developmental history interview.Consent *I understand that for autism evaluations involving an adult (18 years of age or older), at least one parent, guardian, sibling, caregiver, or another individual who is familiar with my early developmental history must participate in the ADI-R developmental history interview. If no one is available to participate, I understand that I should contact the Tucson Alliance for Autism at 520-319-5857 before proceeding so that additional options can be discussed.I understand that the fee for the Comprehensive Autism Evaluation is $1,275I understand that TAFA does not accept insurance at this time, but an itemized receipt can be provided for possible insurance reimbursement.I understand that a $250 deposit is required to schedule an appointment and that the remaining balance is due at the time of the appointment unless payment arrangements have been made in advance.Additional Questions or CommentsWould you like to receive your intake packet digitally or via regular mail? *Digitally (Email)US MailStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal codeWould you like to be added to our quarterly newsletter? *When you subscribe below, you can count on us to keep your inbox calm — we’ll only send occasional updates about upcoming events, community programs, and important announcements related to TAFA.YesNoRequest Evaluation Packet
