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Phone

360.610.7880

tyler@neuroconnectamh.com

Hours

M-Th - By Appointment

NeuroConnect: Autistic Mental Health

Phone

360.610.7880

tyler@neuroconnectamh.com

Hours

M-Th - By Appointment

Home
Services & Fees
About Me
Why the Apple & Orange?
Contact Me
Client Information
Autism Resources
Neuro Spicy Shop

Contact Me

For more information regarding services and scheduling please contact me by filling out the contact form below and I will reach out to you as soon as possible.

360.610.7880

FAX: 360.824.5440

tyler@neuroconnectamh.com

Your name*

Phone*

Email*

Name of potential client (first and last)*

If you are not the potential client and they are 13 or older, please put their email address here (If you are the potential client or they are under 13, write “same”)*

Phone number of client if 13+ or not the person completing this form*

Relation to potential client*

Age of potential client (years)*

Current occupation of the potential client*

Preferred time of day for session start time (select all that apply for your current availability)*

Mornings (830-1030am)

Mid-day (1-2pm)

Afternoon (3-4pm)

Monday

Tuesday

Wednesday

Thursday

Please select the county you will be in when receiving services (you must be in WA State during the appointments)*

Do you have insurance? (See Services & Fees for insurances that are in-network) *OON=out of network*

Any current mental health diagnoses*

ADHD

Anxiety

Autism

Depression

Other

None

What type of service are you looking for?*

Does the potential client currently have a diagnosis of Autism or do you suspect that they may be on the spectrum?*

Military Service (please select all that apply)*

No connection to the military

Currently serving (Active Duty)

Currently serving (Reserves)

Family member serves (spouse, parent, sibling, child)

Retired or no longer serving

Why are you seeking counseling at this time?*

How were you referred to NeuroConnect Autistic Mental Health?*

Please be advised that only telehealth (video/phone) sessions are available*

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