Supporting Every Child's Journey

Ready to get started? Share your information below and our intake team will reach out to help your family take the next step.

Get Started

Client Information

Tell us about the person seeking services.

Client full name *

Date of birth *

Gender

Primary language

Client address

Preferred clinic location

Guardian / Contact

Guardian name

Relationship to client

Phone *

Email *

Emergency contact

We do not send promotional SMS from website forms. Any text messages, if used for active clients, are limited to required service updates such as appointment reminders, holiday notices, or care-related updates.

Referring Party (optional)

Complete this section if you are referring a client to Autizum.

Referring name

Agency / organization

Referring phone

Fax

Referring address

Insurance (optional)

Insurance provider

Select or leave blank

Member ID

Policy number

Policy holder name

Policy holder relation

Services & Clinical Info (optional)

Requested services

Reason for referral / concerns

Diagnoses

Has received ABA therapy before

Additional notes

Contact Info

1031 Pemberton Hill Rd #102
Apex, NC 27502

(919) 910-4058

intake@autizum.com

Open Mon - Fri, 9 AM - 5 PM EST