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FSU Center for Autism and Related Disabilities (CARD)

Referral/Intake

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About
- Autism Institute
- FSU CARD
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Referral/Intake Adult with Guardian

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

Data was NOT saved. Correct the following errors and save again.

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?

Which Numbers:

Home

Work

Cell

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?

Which Numbers:

Home Work Cell

** PLEASE INCLUDE GUARDIANSHIP DOCUMENTATION **

How do you plan to send the guardianship document?

Mail Upload Fax Trying to Schedule Evaluation

Guardianship File

FSU Center for Autism and Related Disabilities
2312 Killearn Center Boulevard, Buliding A
Tallahassee, FL 32309

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Panama City Center for Autism and Related Disabilities
4750 Collegiate Drive, Barron Building, Room A303
Panama City, FL 32405

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Pensacola Center for Autism and Related Disabilities
One Pensacola Plaza
125 W Romana St., Suite 222
Pensacola, FL 32502

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Center for Autism and Related Disabilities

FAX: (850) 644-3644

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?

Which Numbers:

Home Work Cell

Diagnosis

Diagnosis:

By Whom:

Date:

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

*How do you plan to send the diagnosis document?

Mail Upload Fax Trying to Schedule Evaluation

Diagnosis File

FSU Center for Autism and Related Disabilities
2312 Killearn Center Boulevard, Buliding A
Tallahassee, FL 32309

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Panama City Center for Autism and Related Disabilities
4750 Collegiate Drive, Barron Building, Room A303
Panama City, FL 32405

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Pensacola Center for Autism and Related Disabilities
One Pensacola Plaza
125 W Romana St., Suite 222
Pensacola, FL 32502

(850) 644-4367
toll-free: (800) 769-7926
fax: (850) 644-3644

FSU Center for Autism and Related Disabilities

FAX: (850) 644-3644

Under the age of nine without a diagnosis: FSU-CARD does not require a diagnosis of ASD for children who are under 9 years of age. Eligibility for these children is determined through a screening process that may include use of questionnaires, interviews, and/or direct observation. Once your referral is submitted, a staff member will contact you regarding questionnaires to determine eligibility. Children determined eligible through the screening process will be required to obtain a formal diagnosis of ASD by age 9 in order to remain a CARD client.

Date Evaluation Scheduled:

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

What are your primary concerns?

Communication

Challenging behavior(s)

Education/School/Academic related

Employment

Housing

Toilet training

Seeking a diagnosis

Social skills/Interaction

Understanding autism spectrum disorder

Other

Where can we assist you?

Home

School

Community

Work

Other

Does your family receive help from any of the following programs or services? (Check all that apply)

Agency for Persons with Disabilities (APD)

Disability Benefits like SSI (Supplementary Security Income)

Food stamps (SNAP)

Group Home/Intermediate Care Facility (ICF)/Institutional Care

Housing Assistance

Medicaid

Phone or Fuel Assistance

Supported Employment

Supported Living

Unemployment

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.)

Acceptable Diagnosis Documents

To comply with the legislative rule under which we function (1005.55), documentation of a diagnosis of ASD or Related Disabilities must be submitted for individuals 9 years of age and up or by the completion of 2nd grade, whichever occurs first. Examples of appropriate documentation include:

Diagnostic evaluation reports
School evaluations
Individualized Education Program (IEP) indicating exceptionality Autism/ASD as an exceptionality.