Start your Journey!

Intake Process

Intake & Connection

We’ll connect with you, learn about your child’s needs, and guide you through every step of the journey.

1

Personalized Plan

Together, we’ll design a personalized therapy plan that highlights your child’s unique strengths and goals.

2

Begin Services

Therapy starts! We provide continuous support and keep you updated every step of the way.

3

✨ Referral Options ✨

We accept referrals through email, fax, or our secure online form:

📩 Email: zak@willowautism.com
📠 Fax: (651) 430-1750
📝 Online Form: Complete the secure form below ⬇️

Online Intake Form — Open to Parents/Guardians, and Professional Providers

Referrer information

Your Name

First Name

Last Name

Organization / Clinic Name:

Relationship to the Child

Phone Number

(###)

###

####

Parent/Guardian Contact Info

Parent/Guardian Full Name

First Name

Last Name

Phone Number

(###)

###

####

Client Information

Full Client Name

First Name

Last Name

Date of Birth

Insurance provider

PMI:

Disclaimer

We take reasonable steps to protect the information you share through this form. However, we cannot guarantee that data sent over the internet will not be intercepted. By submitting this form, you understand these risks and agree that Willow Autism Center is not responsible for any information compromised during transmission. For your protection, we recommend using secure, up-to-date security software.

Text Message Terms & Conditions

By clicking "Submit Form," I consent to receive non-promotional text messages from Willow Autism Center regarding services, appointment reminders, and updates related to my inquiry. Message frequency may vary. Message and data rates may apply. Reply STOP to unsubscribe or HELP for more information. View our Privacy Policy to learn how your data is used.

Start your Journey!

Intake Process

Intake & Connection

1

Personalized Plan

2

Begin Services

3

Online Intake Form — Open to Parents/Guardians, and Professional Providers

About

Contact Info