Online Admission Application

Child's Name *
Child's Name
Birthdate *
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Address *
Parent/Guardian Address
Parent/Guardian Phone *
Parent/Guardian Phone
Does your child have a medical diagnosis of autism?
Date of Diagnosis *
Date of Diagnosis
Who referred you to The Spectrum Center for Autism?
Insurance Holder's Birthdate *
Insurance Holder's Birthdate
Insurance Plan's Contact Number *
Insurance Plan's Contact Number
Enter the phone number for PROVIDERS to call located on the back of your insurance card