# Autism defined

Autism spectrum disorder, or ASD, impacts the brain development of a child, impacting the way they socialize, communicate and behave. No diagnosis is the same, and the effects of autism are deeply unique to each child.

## Yes, I am interested in a virtual autism diagnosis for my child

Fill out this form and we will contact you directly

### Diagnosis Form

- First Name\*
- Last Name\*
- Email\*
- Phone number\*
- Zip code\*
- City\*
- What year was your child born?\*
- Who is your in-network insurance provider?\*
  - Aetna
  - Aetna Better Health Medicaid
  - Anthem
  - CareFirst
  - Fidelis Care Medicaid
  - Horizon NJ Health Medicaid
  - Oklahoma Complete Health
  - United Healthcare Community Plan Medicaid
  - Wellpoint Medicaid
  - Self-Pay  
- State\*
- Serviceable status\*
  - Coming Soon
  - In Service Area
  - Out of Service Area
- Team assigned\*
  - LSQ Team 1
  - LSQ Team 2
  - LSQ Team 3
  - LSQ Team 4
- Pod\*
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  - Baltimore
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  - Broken Arrow
  - Capitol Hill
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  - Chula Vista
  - Columbia
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  - San Luis Obispo
  - Santa Barbara
  - Springfield
  - Tri Counties
  - Tulsa
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- Form Submitted Phone\*

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