INFORMATION ABOUT THE PERSON WHO MEETS REGISTRATION CRITERIA:
      
Last Name:         
First Name:	
Street Address:	

City:		 , FL

Zip Code:	
Phone:		(EX: 321-555-5555)
Date of Birth: 	Choose
(mm/dd/yyyy)

Gender:		Male	Female


County: 	Brevard  Seminole	Lake     Sumter
        	Orange   Volusia 	Osceola   


Referral Source:	  
Person Completing Survey: 


Family and Household Members(name, age, relation):
  
  

PARENT/GUARDIAN INFORMATION:
    

E-Mail Address:	
Last Name:	
First Name:	

Street Address:	
City:		  State:   

Zip Code:	

Phone:		
Work phone:	 ask for: 

Cellular/Pager:	

County: 	Brevard  Seminole	Lake     Sumter
        	Orange   Volusia 	Osceola   

EDUCATION INFORMATION:

Because we are a state agency, we are required to demonstrate we are serving all 
eligible constituents in our area. Collecting the following demographic data will 
enable us to provide that information.

Asian		Native American	Black/African American  Pacific Islander
Hispanic	White/Caucasian	Middle Eastern
                
Do you speak English:	Yes	No

Primary Language spoken in the home:
English         Japanese
Spanish         Korean       
Chinese	     Other:  						     
Italian         
German  

School District:         
School Name:     
Grade:                    

Teacher:         

Classroom Type:  
Current Services and Therapies:
  

MEDICAL HISTORY

Diagnosis:
    Asperger's Syndrome	Autism		Autistic-like		CDD
    PDD/NOS			Rett Syndrome		Pending Evaluation/Diagnosis
       
Other Eligibility:
    Deaf-Blindness		Hearing Loss		Vision Loss
   


Evaluator(who made the diagnosis):  
Date of the diagnosis:(mm/dd/yyyy): Choose

Are you using any of the following services for the person you are registering?
Children's Medical Services (CMS)?  YES  NO
Developmental Services?        	    YES  NO


Medicaid? 		            YES  NO

Health Status/Other Disabilities (vision/hearing/asthma/allergies/etc?):
 

Medications (name of medication, dosage, and who prescribed it):
 

Current concerns (What would you like us to help you with?):
 


  

    Enter Security Code: