CARD Referral/Intake

Referral/Intake Child

Thank you for visiting the Center for Autism and Related Disabilities (CARD) online referral site. CARD is a state funded agency whose purpose is to serve individuals with Autism Spectrum Disorder (ASD) or Related Disabilities, their families, schools, and community. While CARD is able to provide a variety of supports to clients and families, CARD does NOT provide evaluations, diagnoses, therapies, or respite care.

All of CARD services are FREE of charge. Please fill out this referral form as completely as possible. You can save this form and come back later if you cannot complete it at this time. You will be asked to create a login so that you can return. Once the form is complete you can submit to CARD for review.
You will be contacted by CARD staff when your referral form has been received.

Please note: Your information will remain confidential to the extent allowed by Federal and State laws. All personal information provided is exempt from the Florida Sunshine Law.

For more information, please see our website: fsucard.com

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Referral for

*First Name:

*Last Name:

MI:

*Date of Birth:

*Gender:

*Race:

*Ethnicity:

*What is your Annual Household Income?

Mailing Address:

City:

State:

Zip:

*County:

Email:

Home Phone:

Work Phone:

Cell Phone:

May we leave a voice message?

Parent/Guardian

*First Name:

*Last Name:

*Mailing Address:

*City:

*State:

*Zip:

County:

Email:

Home Phone:

Work Phone:

Cell Phone:

May we leave a voice message?

** PLEASE INCLUDE GUARDIANSHIP DOCUMENTATION **

How do you plan to send the guardianship document?

Mail Upload Fax Under the age of nine without a diagnosis

Parent/Guardian (if different)

First Name:

Last Name:

Mailing Address:

City:

State:

Zip:

County:

Email:

Home Phone:

Work Phone:

Cell Phone:

May we leave a voice message?

Diagnosis

Diagnosis:

By Whom:

Date:

** A COPY OF AN EVALUATION REPORT DOCUMENTING DIAGNOSIS IS REQUIRED **

To comply with the legislative rule under which we function (1004.55), documentation of a diagnosis of Autism Spectrum Disorder (ASD) or Related Disabilities must be submitted for individuals ages 9 and up or by the completion of 2nd grade, whichever occurs first. Examples of appropriate documentation include: diagnostic evaluation reports from a neurologist, physician, psychiatrist, psychologist, or social worker. Documentation may also include school evaluations or Individualized Education Plans (IEPs) indicating Autism/ASD as the educational exceptionality.

*How do you plan to send the diagnosis document?

Mail Upload Fax Under the age of nine without a diagnosis Trying to Schedule Evaluation

Health

Other Health Concerns:

Medications:

Employment (if applicable)

Place of Employment (if applicable):

Contact Name:

Phone:

Mailing Address:

City:

State:

Zip:

School (if applicable)

Name of School:

Type of Class:

Contact Name:

Phone Number:

Grade:

School Therapy Services/Agencies

Other

Where can we assist you?

Home

School

Community

Work

Other

Other Agencies/Service Providers:

Were you referred to CARD? If so, by whom?

Name/Title:

Agency:

Mailing Address:

City:

State:

Zip:

Phone:

Create Login if you plan to return to form

If you cannot complete the entire form all at once, you can create a login so that you can save the form to complete later.

User Email:*

Password:*

(Must be at least 8 characters long and have at least one number and one upper case letter.)

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Referral/Intake Child