DePelchin Children's Center
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Request Autism Information


To find out more information about DePelchin Autism Services, complete the form below:   

Your Name:
Street Address:
City:
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ZIP Code: 
Email Address:
Daytime Phone:
Child's Name:
Child's Date of Birth:  mm/dd/yyyy
Contact Me By:  Email       Phone
 
What services are you interested in?
  Autism Assessment                   Individual Counseling            Independent Education Evaluation   
  Social Thinking Groups            Psychiatric Evaluation           Teacher Training
  Autism Information Series        Medication Management      Family Counseling                                 
  Parent Training                     
             

Why are you seeking services at this time?


How did you learn about DePelchin Autism Services? (click all that apply):
  Website                          Pediatrician:  
  TV/Radio                       School:                           
  Mailer/Letter                  Other:                
  Email                          
                     
  
   
   

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“DePelchin”, “DePelchin Children’s Center” and the window/sun logo
are registered trademarks of DePelchin Children’s Center. 		DePelchin Children's Center gratefully receives its support
from government grants and fees, United Way agencies,
corporations, foundations and individuals.