Let's get started.

A few details to begin. This takes about ten to fifteen minutes total, and you can save your progress along the way.

Your first name *

Your last name *

Email *

Cell phone *

Check eligibility.

We're currently licensed in New York and Texas. Telehealth visits are only available to patients physically located in licensed states at the time of each visit.

Child's date of birth *

State where your child will be the day of the evaluation *

A few questions about your child.

These help us understand what brought you here. None of this commits you to anything.

Child's sex at birth *

Female

Male

Has a teacher, caregiver, or physician ever recommended an evaluation for autism? *

Yes

No

Does your child have any siblings diagnosed with autism? *

Yes

No

Any other family members diagnosed with autism? *

Yes

No

Confirm the cost.

Foyer charges a single flat fee. You'll know exactly what you're paying before you book, with no surprise bills afterward.

Comprehensive evaluation

$1,499

Flat fee · paid at the end of booking · HSA and FSA eligible

Three virtual visits with Dr. Levine
DSM-5 aligned diagnostic report
Personalized care plan
Itemized superbill for out-of-network reimbursement
30 days of follow-up messaging with Dr. Levine

I understand that I am responsible for all charges and will not be submitting insurance for this visit. I confirm the information I provide today is accurate and complete to the best of my knowledge.

About your child.

A few logistical details for the chart.

Patient first name *

Patient last name *

Address *

City *

Zip code *

Is your child exposed to any languages besides English at home? *

Yes

No

Helps us interpret speech and language milestones accurately.

What best describes why you're here? *

Referral code (optional)

About you.

A few details so we can confirm your legal authority to consent to care.

Your date of birth *

Relationship to child *

I attest that I am either (a) the parent or guardian and have legal authority to consent to treatment, OR (b) I otherwise have the legal authority to consent to treatment for this child.

My address is the same as my child's address

Would you like to receive text message reminders? *

Yes, send texts

No, email only

By opting in you authorize Foyer Pediatrics to deliver SMS messages for appointment reminders and care coordination. Message frequency varies. Text STOP to opt out anytime. Msg & data rates may apply. See our Mobile Terms and HIPAA Texting Consent.

Required consents.

Three short documents. Click any title to read the full text in a new tab. One signature applies to all.

Informed Consent for Telehealth Services read → I consent to the use of telehealth for my child's medical care and authorize Foyer Pediatrics to use telehealth in the course of diagnosis and treatment. HIPAA Notice of Privacy Practices read → I have received and reviewed Foyer's Notice of Privacy Practices, describing how my child's health information is used and protected. Financial Policy & Card on File read → I agree to Foyer's financial policy and authorize a payment card to be kept on file for the evaluation fee and any incidental charges.

Optional, but recommended:

Consent to Obtain Medical Records I authorize Foyer to request my child's records from prior providers, including any past evaluations, screenings, or therapy notes. Care Coordination I authorize Foyer to share findings with my child's pediatrician, school, or therapy providers when relevant.

One more quick question.

How did you first hear about Foyer? This helps us understand who's sending families our way.

Schedule your first visit.

Pick a time for your intake conversation with Dr. Levine. This is the first of three visits.

Time zone

Eastern (New York, Boston, Washington DC)

Change

Suggested times

Wed Jun 3

Thu Jun 4

Fri Jun 5

Complete payment.

$1,499 charged today to secure your first visit and the full three-visit evaluation. HSA and FSA eligible.

Name on card *

Card number *

Expiration (MM / YY) *

CVC *

Billing address is the same as my address

Payment processed securely by Stripe. Foyer never stores your full card number. By submitting you agree to the Card on File Agreement.

✓

You're booked.

Your first visit with Dr. Levine is confirmed. We've sent a confirmation to your email along with your pre-visit medical history forms.

Please complete the pre-visit medical history at least 48 hours before your appointment so Dr. Levine can prepare. It takes about 15 to 20 minutes.

Start medical history →

Run the booking flow again