Autism-1

MRT℠ treatment

Brain Treatment Center

Sign up here!

Schedule an appointment: BTC Staff will contact you. (Due to limited space there may be a waiting list.)

Child's First Name *

Child's Last Name *

Child's Age *

Guardian contact information:

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Email Address *

Which has your child been diagnosed with:

Autism

Asperger’s

How many hours, on average, does your child sleep every night? *

Has your child had any brain operations? If yes, do they have:

shunts?

stents?

aneurysm clips?

electrodes or implants of any kind?

Does your child have any of the following:

How would you rate the severity of your child's Autism? *

Mild

Moderate

Severe

Preference for treatment date? Additional information

0/1000 characters