Community Provider Referral Form

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This form is to be completed by the healthcare provider that is familiar with the care of the patient.

Today's Date

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M-D-Y

Child's Legal First Name

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As shown on insurance card.

Child's Legal Last Name

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As shown on insurance card.

Sex

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Male Female

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Date of Birth

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M-D-Y

Legal Guardian First Name

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Legal Guardian Last Name

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Legal Guardian Phone Number

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Guardian email address

Please select the primary service you are requesting.

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NEW ASD DIAGNOSIS (The child needs a formal evaluation to determine if he/she has Autism (ASD).

ESTABLISHED ASD DIAGNOSIS The child has already been evaluated and received a formal diagnosis of Autism (ASD) and needs the following service.

Child does NOT have AUTISM but have concerns about feeding.

Child does NOT have AUTISM but has a diagnosis of developmental delay and/or intellectual disability and have concerns about problem behavior management..

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Please select the characteristics of autism that you have concerns for and are requesting a formal evaluation for ASD.

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SOCIAL CONCERNS (less eye contact, difficulty understanding the emotions and feeling of others, problems making and keeping friends.

COMMUNICATION CONCERNS (lack of speech,slow to learn speech, unusual speech (repeats things, unusual sounds), difficulty making conversation.

REPETITIVE BEHAVIOR OR RESTRICTED INTERESTS (rocks, spins, flaps hands, uncommon strong limited interests, plays with parts of toy i.e. spins wheels of toy car).

PROBLEM BEHAVIORS (aggressive towards others, hits,bites, kicks, self injurious behavior, head bangs, scratches self, picks at skin, elopement, PICA (chews/mouths vs swallows)

Select the primary service that you are interested in referring this child.

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Developmental follow-up .

Medication Management (initiation of medication or management of existing meds)

Behavioral management (does not include medication management)

Neurological evaluation (please state specific concern)

Neurodiagnostic testing (EEG, Neuroimaging, Genetic testing)

Language and Skill Acquisition (ABA therapy)

Feeding Evaluation

Other

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Select additional services that you are interested in referring this child.

Developmental follow-up

Medication Management (initiation of medication or management of existing meds)

Behavioral management (does not include medication management)

Neurological evaluation (please state specific concern)

Neurodiagnostic testing (EEG, Neuroimaging, Genetic testing)

Feeding Evaluation

Therapies (Speech therapy, Occupational therapy, or ABA therapy).

Other

We are not accepting new referrals for Neurology services at this time. Please make another selection or if you have questions, contact us at 404-785-9400.

Please state specific concern for requesting a neurological evaluation

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Please state other service you are requesting for this child.

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Please state specific concern for requesting feeding services

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PLEASE COMPLETE THE MEDICAL INFORMATION BELOW:

Check all that apply:

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No known medical problems

Prematurity (gestational age)

Cerebral palsy or other brain injury/abnormality

Seizures/Epilepsy

Developmental regression

Genetic syndrome

Hearing Impairment

Vision Impairment

Cardiac defect

Other relevant medical condition

What was the child's gestational age at birth?

In weeks

If known, please specify brain injury/abnormality.

Please specify genetic syndrome.

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Specify other relevant medical conditions

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List all medical or psychiatric Diagnoses.

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Please describe specific concerns for referring this child for an ASD evaluation or other services at the Marcus Autism Center.

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Provider Name

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Practice Name

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Group or Organization Name

Provider Phone Number

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Provider Email Address

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This email address may be used to communicate with you about the patient referral.

I certify that I am the child's healthcare provider or office representative of the healthcare provider completing this form.

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Yes No

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Please contact your child's healthcare provider to submit our online provider referral form at www.marcus.org to request services for your child.

Name of office representative completing this form

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Phone contact information for office representative

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EPIC MRN Number

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Date Registration Cleared

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M-D-Y

PCQ email sent

M-D-Y

PCQ mailed to home address

M-D-Y

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Required format:

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

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