Referral and Service Request Form

Referrals for Autism Evaluations can be made by any individual.  

Click HERE to complete our Autism Evaluation referral form online.

Para completar nuestra referencia en español en línea, haga clic en
AQUÍ.

Si requiere asistencia en Español comuníquese con Yachira Rosario Diaz al 203-920-0520 ext. 1064

We accept Husky A, C, and D. We are out-of-network for all other insurances.

 Or, download the referral form below and fax it to us at 203-266-1005. You may also email the referral form to sara.brown@familystrongct.com.