Spectrum of Hope- Health Wellness and Community Services INQUIRY FORM

Thank you for reaching out to Spectrum of Hope!
 
Please complete the following form on behalf of your child/ youth or on behalf of a child/ youth that you serve and support professionally. 
 
If you are a community provider or organization seeking training, professional development and/or consulting please complete as well.
 
We look forward to serving you!
I am a (Please check all that apply): *
 
I was referred to Spectrum of Hope by: *
 
Are you a parent or caregiver seeking assistance for your child(ren) or youth or a professional/provider seeking assistance for a child(ren)/ youth for whom you provide services? *
Please indicate what services you are seeking assistance with: (CHECK ALL THAT APPLY) *
 
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Please note the information below is to be completed by a family member/ caregiver or provider/ professional seeking assistance for a child/ youth.
 
*Please do not complete if you are seeking Community Services such as outreach, training or consulting.  
Please indicate which Spectrum of Hope services you would like assistance with for the child/youth referred? (CHECK ALL THAT APPLY) *
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Child/ Youth Sex: *
Child/ Youth Racial Identity (This information assist us in understanding equity in access to care) *
 
Has the child/youth been screened for developmental delays by their healthcare provider or another professional using a screening tool such as the ASQ-Ages and Stages Questionnaire or PEDS-Pediatric Evaluation of Development? *
Has the child/youth been screened for Autism by their healthcare provider or another professional using a screening tool such as the MCHAT- Modified Checklist for Autism in Toddlers? *
Does the child/ youth have a diagnosis of Autism? *
What are the child's/ youth's past and/ or current supports and therapeutic interventions? (CHECK ALL THAT APPLY) *
 
What ADDITIONAL Supports are you seeking for the child's/ youth's for which you are making an inquiry for? (CHECK ALL THAT APPLY) *
 
Thank you we will be in touch with you shortly!
Please email brenda@spectrum-hope.com  or
nataly@spectrum-hope.com for additional assistance.