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Apply for Diagnostic Assessment Support

Please fill out this form as thoroughly as possible and we will reach out to you.

Caregiver's First Name (Required)

Caregiver's Last Name (Required)

Child's Date of Birth (Required)

Email (Required)

Phone (Required)

Street Number and Street Name (Required)

City or Town (Required)

Province (Required)

Postal Code (Required)

Is your child walking? (Required)

When was your first contact with CHEO or First Words? (Required)

How did you hear about QuickStart Early Intervention for Autism?

Reason for contacting us? (Please be specific about what signs of autism you are seeing.)

When did you first become concerned about your child's development?

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