Clinical E-take Form   Step 1           Patient Information         * Patient First Name     Patient Middle Initial   * Patient Last Name   * Patient Date of Birth   /   /     Contact Information / Guardianship Information         *  Last Name   * First Name   * Phone     Alternate Phone     Other Phone   * Address 1     Address 2   * City   * State   * Zip Code   * E-mail Address     Do you need an interpreter?   Please select Yes No * Language   Select a Language English Korean Russian Spanish Vietnamese Other   Comments     Is anyone in your family employed by Children’s Healthcare of Atlanta?   Please select Yes No   Name     Relationship   * What is your relationship to this child?   What is your relationship to this child? Biological Parent Adoptive Parent Foster Parent Family Member Friend Doctor’s Office DFACS Other   Other             Do you have legal custody of this child to make medical appointments and decisions? * Please select Yes No     If you are the legal guardian, have guardianship papers been submitted and received? * Please select Yes No     Comments     Referral Information           Were you referred to Marcus Autism Center?   Please select Yes No   Referral Type   Please select Self-Referral Physician/psychologist School Other   Other     Name of Individual or Provider’s office making referral:     Is this your first visit to Marcus Autism Center?   Please select Yes No   How long ago were you here?