Confidence Connection

Center for Children with Autism

Are there any interfering behaviors? *

Secondary Insurance *

What services/needs are you looking for? *

What does your child’s educational and therapeutic program look like? *

Additional Notes:

How does your child communicate? *

Age/DOB: *

What are you child's strengths/weaknesses? How are their play skills? *

Contact Us

What are some of your child’s favorite things (movies, toys, music, foods, iPads?) *

Email: *

Primary Insurance: *

Facebook

Parent Name: *

What are the parent's goals/objectives for the child? *

Any other concerns? *

Child's Name: *

Phone Number *