WE’RE HAPPY TO MEET YOU! "*" indicates required fields 1Patient2Caregiver3Insurance4Scheduling We're happy to meet you! To get started, we need to register an account for your child and then get you scheduled. Your information is secure with us, and we never share it without your permission.Checkbox* I consent to the terms of use and have read the privacy policy. 1. Has your child been diagnosed with autism by a medical doctor or psychologist?* Yes No 2. Are you seeking a diagnostic evaluation to see if your child has autism?* Yes No Are you seeking therapy services for any of the following:* Yes No Autism; ADHD; developmental delay (such as delays in speech, motor, or cognitive development); intellectual, cognitive, or learning disability; sensory processing disorder; cerebral palsy; genetic syndrome; or epilepsy. Patient DetailsFull Name* First Last Gender*AgenderBigenderCisgender FemaleCisgender MaleDecline to SpecifyGenderfluidGender NonconformingNonbinaryTransgenderOtherBirth Date* MM slash DD slash YYYY Patient AddressAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United States Country Nearest Cortica CenterNearest Cortica Center*First ChoiceSecond ChoiceThird ChoiceHow did you hear about Cortica?GoogleBingeFacebookInsuranceInstagramOthers Are you the patient's primary Caregiver? Yes No Are you the legal guardian? Yes No EmailThis field is for validation purposes and should be left unchanged.
