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: *

Your First name: *

Your Last Name: *

Your best email: *

Your best telephone number: *

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? *

Yes

No

Organization or entity with whom you are affiliated, if applicable:

Please indicate what services you are seeking assistance with: (CHECK ALL THAT APPLY) *

PGSNIPS-Prince George's County Special Needs Identification Physician Support Program

Community Training/ Event Participation

Professional Development

Consulting/ Community Planning

Other Other

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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) *

Autism Diagnostic Evaluation

Medical Consultation for a child/ youth with Autism and/or related developmental difference

Family Support/ Guidance

MAMAS- Mother's Support Group (Mothering Authentically Mindfully and Aware of Self)

Father's / Male Caregiver Support

You indicated that you are seeking an Autism Evaluation, is this a 2nd opinion or a re-evaluation for services. *

Other reason for Autism evaluation: *

First Name of Child/ Youth *

Last Name of Child/ Youth: *

Child/ Youth Date of Birth: * +

Child/ Youth Sex: *

female

male

prefer not to disclose

Child/ Youth's age at the time of inquiry: *

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? *

Yes

No

Unsure

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? *

Yes

No

Unsure

Does the child/ youth have a diagnosis of Autism? *

Yes

No

Child/ Youth's age at the time of diagnosis: *

When was your child's last Autism evaluation? *

Which professional diagnosed your child/youth with autism? *

Please indicate the district/ county that your child/ youth receives educational services from? *

Other *

Please select the Prince George's County Public school your child is enrolled in: *

Which Non-public School does your child / youth attend? *

As a parent or caregiver of the child/ youth being referred, please rate your LEVEL OF STRESS when it comes to caring for / parenting your child/ youth: *

As a parent or caregiver of the child/ youth being referred, please rate your LEVEL OF SUPPORT from others when it comes to caring for your child: *

What are the child's/ youth's PAST supports and therapeutic interventions? (CHECK ALL THAT APPLY) *

What are the child's/ youth's CURRENT supports and therapeutic interventions? (CHECK ALL THAT APPLY) *

Please indicate name of Speech Therapy Provider: *

Please indicate name of Occupational Therapy Provider: *

Please indicate name of Physical Therapy Provider: *

Please indicate name of Behavioral / Mental Health Provider: *

What ADDITIONAL Supports are you seeking for the child's/ youth's for which you are making an inquiry for? (CHECK ALL THAT APPLY) *

Does your child/ youth have health insurance? *

Insurance Type *

Medicaid MCOs *

Private Plans *

Other Insurance *

Has the child/you or their family been been involved in autism related research currently or in the past? *

Thank you we will be in touch with you shortly!

Please email brenda@spectrum-hope.com

for additional assistance.