Request an intake

If you are ready for new approach, fill out the form below or contact us at any time.  You will receive a response from a real person within 24 hours. 

 
Name *
Name
Request For
Are you requesting an intake for yourself or on behalf of a loved one?
Please tell us a few challenges recently that you would like to discuss further at your intake.
Please list 2-3 things you would like to see as an outcome to services at Autism Family Center.
Programs Interested In *
Check all that apply.
Center (Location) *
Please select the center location that is more convenient
Please list a few days and times that you and your family are available for an intake.
How did you hear about us? *
Insurance Provider

 

CONFIDENTIALITY NOTICE: Please note limits of confidentiality when submitting personal information electronically. When you fill out this form, you will receive a response by email which may include the information provided in your form. Autism Family Center's emails are not encrypted and choosing to communicate via email and other methods of electronic communication may come at a risk for interception. If you are uncomfortable submitting the information electronically, please call Lauren Rabin: 847.814.1096. Thank you!


Need More Info? 

Not ready for an intake yet? To learn more, click below or reach out to us at any time.

 

 

CONTACT

Lauren Rabin

President, Founder     |      847.814.1096      |        laurenrabin@autismfamilycenter.com

 

Leighna fischer, BCBA

Director of Behavior Analysis    |      lfischer@autismfamilycenter.com 

 

Kathryn Jackson, lcpc

Lead Family Therapist    |     kjackson@autismfamilycenter.com