Physician Referrals

The Multi-Discipline Autism Referral Evaluation Form is prefilled with all necessary services selected to schedule an autism evaluation.

Multi-Disciplinary Therapy Program Referral Form is prefilled with all necessary services selected to join a therapy program.
Per patient need, ABA and feeding services may also be selected by the referring physician.

Multi-Discipinary Autism Evaluation Referral Form (pdf)Download

Multi-Disciplinary Therapy Program Referral Form (pdf)Download

Please fax all referrals to 734-527-5981

If you do not use our referral form, please be sure that your referral is legible and includes:

Patient name & date of birth
Patient contact information
Patient diagnosis/suspected diagnosis
Type of service is requested
The referring physician’s printed name, signature, and date
- Referrals expire after 90 days, please be sure to send a non-expired referral.

Please direct your patients to our website begin the intake process.

New Patient Intake

Physician Referrals

Please fax all referrals to 734-527-5981

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