OASN Neurodevelopmental Intake Up to 21 years old

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Name of Individual up to the age of 21* This field is required.If your child or you as the individual will be turning 22 soon, please talk to our staff about referrals for services.
First Name
Middle Name
Last Name
2
I acknowledge that the I/the person I am completing this intake form for lives within reasonable driving distance of Ocala, FL. I am completing this intake form because I intend on participating in programs, services and events offered at Outreach Alliance Supporting Neurodevelopment (OASN).* This field is required.
I acknowledge that I currently reside in the state of FL and within driving distance of Ocala, FL.
I acknowledge that I am moving to the state of FL and within driving distance of Ocala, FL.
3
Please select the neurodevelopmental diagnosis (or diagnoses) for the individual up to age 21 has:* This field is required.
an ADD/ADHD diagnosis.
an ID (Intellectual Disability) diagnosis.
a learning disorder diagnosis.
My child (up to age 6) has a developmentally delayed (DD) diagnosis.
an autism diagnosis from a pediatrician or family doctor but does not have a comprehensive diagnostic report.
an autism diagnosis from my pediatrician or family doctor AND have a comprehensive diagnostic report.
4
Please attach your comprehensive diagnostic report, letter or other report stating that you or your child has a neurodevelopmental disorder.
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Age* This field is required.
6
Developmental age (if this does not apply to you or your child, please skip to birth date)
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Birth Date* This field is required.
Month
Day
Year
8
Gender* This field is required.
Male
Female
9
This form is being completed by* This field is required.
Parent/Guardian of a child up to age 18.
Young adult ages 18-21 (adult completing form for him/herself)
Parent/Guardian of a young adult (ages 18-21)
Grandparent of a child/young adult up to age 21
CARD
DCF
Social Worker (not through DCF)
Counselor
Family Member (not grandparent)
School employee (not otherwise listed)
10
Do you give OASN your permission to forward this intake form to other providers, agencies/non profit organizations, medical or therapeutic offices to assist you in getting services in place for your child or for you?* This field is required.
Yes, you have my permission.
No, you do not have my permission.
11
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Parent/Guardian # 1 Name:* This field is required.If this is a young adult completing this application, please put not applicable or NA
13
Parent/Guardian # 1 Cell Number* This field is required.If this is a young adult completing this application, please list your phone number.
Area Code
Phone Number
14
Alternative Phone Number Parent #1
Area Code
Phone Number
15
Parent/Guardian #1 E-mail* This field is required.
16
Do you want to be added to our email list for at least quarterly newsletters (we strive for monthly, but generally you will receive a quarterly newletter from OASN). Special note-you can unsubscribe from our E News at anytime.* This field is required.
YESNO
17
Parent/Guardian #2 NameRequired UNLESS there is no additional parent or guardian legally in child's life OR if you are a young adult completing this form.
18
Parent/Guardian # 2 Cell Number
Area Code
Phone Number
19
Alternative Phone NumberParent #2
Area Code
Phone Number
20
Parent/Guardian #2 E-mail
example@example.com
21
Household size * This field is required.OASN is required to collect this information to receive grant funding that keeps our programs & services low cost or no cost to you. This information about your family specifically regarding income, ethnicity & race is confidential. Thank you.
22
Image FieldPlease look at this chart and tell us your family size & income level based upon the 2024 Federal Poverty Level (participation in this program is NOT INCOME DEPENDENT but this information must be collected to satisfy grant requirements). You can hit the previous button if you forget what your family income percentage level is.
23
Please choose your income bracket (each percentage level is the maximum you can make-ex. A family of 2 at the 133% federal poverty level makes no more than $26,228)* This field is required.OaSN is required to collect this information to receive grant funding that keeps our programs & services low cost or no cost to you. This information about your family specifically regarding income, ethnicity & race is confidential. Thank you.
100% Federal Poverty Level
133% Federal Poverty Level
150% Federal Poverty Level
200% Federal Poverty Level
250% Federal Poverty Level
300% Federal Poverty Level
400% Federal Poverty Level
Above 400% Poverty Level
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Ethnicity* This field is required..
Hispanic
Non Hispanic
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Race* This field is required.
White
Black/African American
Asian
More than one race
Unreported
26
Who referred you to OASN (if applicable)
27
If this intake is being completed for a school age child (up to age 22) a current recipient of the Empowerment Unique Abilities Scholarship? If individual is above the age of 18 and no longer in school, please answer. * This field is required.
YESNO
28
Does your child currently receive ABA services?* This field is required.
YESNO
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Please describe any current issues the individual with a neurodevelopmental disorder up to age 21 is experiencing.
30
Does the individual up to age 21 have any of the following?* This field is required.
Seizures
Visual Impairment
Hearing Impairment
Medication or Food Allergies
Food Intolerances
I will list additional diagnoses below
None
31
Does the individual up to age 21 have any co-morbid (additional) diagnoses? If so, please list the additional diagnoses below (please elaborate on seizures, hearing impairment, visual impairment, medication/food allergies/special diet, etc in addtion to any other diagnoses (if none, please write NA-noting that if you do not tell us about a medical condition, diagnosis, etc. we will not know-providing more information helps us to better serve you especially when you participate in our programs and services):* This field is required.
32
Please list any supplements and/or medications the individual up to age 21 takes if any. If none, please list none. * This field is required.
33
Does the individual this form is being completed for potty trained? If you are uncomfortable with this question, or it does not apply, you may skip this question.
YESNO
34
Please provide medical insurance information for individual with a neurodevelopmental disorder up to age 21:* This field is required.Providing this information helps us provide referrals to you.
35
Is your insurance offered through* This field is required.
Medicaid (through DCF)
Healthy Kids funded
Private insurance through Healthcare.gov
Private insurance (not through Healthcare.gov)
My child does not have insurance/I am a young adult and do not have insurance
I need assistance to obtain insurance for my child/I need assistance obtaining insurance.
36
Name of individual's (up to age 21) Doctor, ARNP or Primary Care Provider (please include phone number)* This field is required.
37
Does the individual with a neurodevelopmental disorder up to age 21 currently receive special education services ?* This field is required.
YESNO
38
Current school-based services that the child receives (full disclosure is needed to assist you with referrals or providing needing supports or accomodations, if possible). If your child is not in school or does not receive or require supports, please check an option below accordingly :
None-child is in a public or private school bur receives no supports, services or accomodations.
N/A my child is not in school
Inclusion Classroom
Speech therapy
Occupational therapy
Physical Therapy
ABA Therapy
My child is in a TUB unit.
Other behavioral supports that I will explain in the area provided below. (not ABA)
My child is provided supports/accomodations in a home school program or home setting and I will list this below.
My child has other supports/services/accomodations received in their public school. I will explain below.
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What supports/accomodations are provided in the school/academic/home or other settings to ensure safety and the best learning environment? Special note: If the supports/accomodations your child or you need are not listed below, we will not be able to determine if we are able to provide supports/accomodations for OASN programs or programs we refer out to:* This field is required..
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Does the individual up to age 21 attend:* This field is required.
Daycare or Preschool
Early Intervention Program
Public, Charter or Magnet School
Private School
Technical or Vocational Program
Home Education Program-onsite or at home
Hospital Home Bound
PPEC
ADT
NOT APPLICABLE
41
Please list name of current school/home education program/daycare/facility or program that individual with a neurodevelopmental disorder up to age 21 attends.If you are a young adult wtih autism or your child is a young adult with autism not attending a program, please notate this here.
42
Phone Number of school, home education program, daycare, ADT or facility listed above.
Area Code
Phone Number
43
Please list any private therapies (& service providers) that the individual up to 21 years old receives. If none, please notate here. * This field is required.ex: Speech, Occupational, ABA, Physical, Occupational Therapy, etc
44
Communication Abilities* This field is required.IMPORTANT: Select all that apply to help us help you or your chld.
NO issues with communication.
Speaks but has trouble expressing him or herself
Echolalic (repetitive speech)
Can say at least 10 words
Uses words or short phrases to communicate wants, needs, and label things
Primary mode of communication is technological device- "SPELLER"
3-5 discernible speech sounds
Babbling consisting of 5+ speech sounds
No discernible speech sounds (mute or 1-2 sounds)
Primary mode of communication is sign language
45
Approximate number of signs individual with neurodevelopmental diagnosis (up to age 21) uses- ASL:If ASL is not used, please skip this question.
46
Communication device used: Skip this question if a communication device is not used.
47
Vocal or Motor-Stimulating BehaviorsSelect all that apply
Hand Flapping
Spinning
Rocking
Mouthing/Chewing
Making noises
Saying repetitive phrases
NONE
48
Does the individual with a neurodevelopmental diagnosis up to age 21 exhibit aggression to the environment/property, such as throwing/turning over furniture, destroying materials, etc? If so, how often? If none, please notate here. Times per day, week, etc. Please provide as much detail as possible.
49
Does the individual with neurodevelopmental diagnosis up to age 21 respond to sudden environmental changes * This field is required.ex: loud noise, presence/absence of people
YESNO
50
If your child/young adult/young adult completing this form have meltdowns? Are there triggers that you have noticed before a meltdown starts? What interventions have been helpful to your child/young adultwhen he/she has a meltdown (or alternatively, if you are an adult completing this form for yourself, when you do have meltdowns?)* This field is required.If your child/young adult/or young adult completing this form does not have meltdowns, please type N/A below.
51
Does the child/young adult/or young adult completing this form exhibit verbal aggression? If so, how often?Times per day, week, etc.
52
Does the child/young adult/or young adult completing this form elope (leave an area/run away without permission)? If so, how often?Times per day, week, etc.
53
Does the child/young adult/young adult completing this form wander (leave an area with no apparent destination)?* This field is required.
YESNO
54
Check what you would like our staff to assist you with (check as many options that you need assistance with) :* This field is required.
Pyschoeducational evaluation (learning disorders and intellectual disability)
Comprehensive Diagnosis Report (for autism diagnosis)
Functional/holistic medicine doctor, nurse practioner referral
Medical doctor (pediatrician, internal medicine or family doctor) referral-not functional or holistic
Support Meetings
Religiious/Medical Exemption form information
Referral for special needs church program
ABA referral
School Placement
Speech therapy referral
Occupational therapy referral
Referrals to providers (our staff will look through your intake form and make recommendations)
None
55
Please utilize this area to ask our staff questions or provide us with additional information. The more information provided, the more we will be able to assist or refer out to providers/other non profit organizations. If nothing additional required, type NA below:* This field is required.
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Please attach your autism diagnosis, ADHD/ADD diagnosis, Intellectual Disability dagnosis, IEP, 504 plan, therapy notes, or any information you would like our staff to review.
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Please upload a photo of your child/young adult for identification purposes. Thank you.
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58
OASN reserves the right to refuse services based on the following:

Parent or guardian of individual with a neurodevelopmental diagnosis or adult (18-21 years old) individual with a neurodevelopmental diagnosis mistreats our staff (including volunteers), anyone of the individuals or families we serve or service providers.

Stealing property from OASN or any space that we share, lease or use temporarily.

Parent, guardian of individual with a neurodevelopmental diagnosis cussing or swearing at our staff or the individuals and families we serve.

Overuse or abuse of services we provide (trying to use services on multiple occasions unless OASN offers to all individuals we serve or misrepresenting your situation to receive services)

Using OASN name without permission to fundraise or for any other purpose without prior consent.

Not showing up for a service signed up for without a phone call or other contact no less than 24 hours prior to event or service.

Selling any items that are given by OASN such as diapers, nutritional drinks, computer, etc.

Not disclosing supports/accomodations needed in place so that a determination can be made if OASN can provide supports or if a referral for services needs to be made.

We reserve the right to refuse service for any other reason not listed (this is not a common occurrence but we do reserve this right).
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Name of person signing below:* This field is required.
First Name
Last Name
60
By signing below, I acknowledge that I have fully read, understand & will abide by all OASN policies/procedures (listed above & those that are provided for any program, service or event that you register for) and have disclosed any supports/accomodations needed in place. Furthermore, I will not hold OASN, it's subsidiary company, Ocala Preparatory Academy, staff, board, volunteers, those that we contract business to/with, utilize space that has been rented or donated (our facility or other space that we are using for special events), and Heritage Management free from liability at any of our events, services or programs.* This field is required.Use your mouse or finger to electronically sign or name below.
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