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Diagnostic support & parent resources

ASD Evaluation Referral

Beautiful Minds works with a network of trusted diagnosing physicians to help families access ASD diagnostic services. Complete the form below and we'll help coordinate your referral.

Trusted diagnosing physicians — We work with a network of trusted diagnosing physicians to help families access ASD evaluations. Once you submit this form, our team will reach out to coordinate next steps and connect you with the right provider.

Diagnostic referral support

Child info

Parent

Concerns

History

Review

Child information

Basic demographic information about the child being referred

First name *Required.

Last name *Required.

Date of birth *Required.

Sex *Required.

Current school or program

Pediatrician / primary care providerWe may contact this provider as part of the referral.

Parent / guardian information

Primary contact for the referral process

Full name *Required.

Relationship *Required.

Phone *Required.

Email *Valid email required.

Preferred contact method

Phone callText messageEmail

Home address *Required.

Primary insurance *Required.

Member ID (optional)

Developmental concerns

Areas that prompted the request for an ASD evaluation

Please be as specific as possible. This helps us communicate referral priority to our diagnosing physician network and prepare our BCBA for follow-up.

Primary reason for requesting an evaluation *Required.

Areas of concern — check all that apply *

Delayed speech or language Limited eye contact Difficulty with social interaction Repetitive behaviors or routines Sensory sensitivities Restricted interests Difficulty with transitions Regression in skills Challenging behaviors Difficulty making friends Unusual play patterns School or learning difficulties

Please select at least one area.

Age concerns were first noticed

Has anyone previously suggested autism?

Yes — doctorYes — school/therapistNoUnsure

Additional context

Medical & developmental history

Background information to support the referral

Previous developmental or psychological evaluation?

YesNoIn process

If yes — provider, year, findings

Current diagnoses — check all that apply

No current diagnosisDevelopmental delaySpeech / language disorderADHDIntellectual disabilityAnxiety disorderSensory processing disorderGenetic or chromosomal condition

Current services — check all that apply

Speech-language therapyOccupational therapyPhysical therapyABA therapySpecial education / IEPEarly interventionMental health counselingNone currently

Current medications

Relevant medical history

Family history of autism or developmental differences

YesNoUnknownPrefer not to say

Anything else the provider should know

Review your information before submitting. Click Edit to make changes.

Child information Edit

Parent / guardian Edit

Developmental concerns Edit

Medical & developmental history Edit

I confirm the information provided is accurate to the best of my knowledge. I understand this form initiates a referral request and does not guarantee evaluation services or a specific timeline. I consent to Beautiful Minds, PLLC contacting the providers listed as part of this process. Please confirm your consent to submit.

Referral request submitted

Thank you. We have received your ASD evaluation referral request. A member of our team will be in touch within 2–3 business days to coordinate next steps and connect you with a trusted diagnosing physician.

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