OASN Intake Up to 21 years old

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I acknowledge that I live within driving distance from Ocala, FL. I am completing this intake form because I intend on participating in programs, services and events offered at 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.
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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
3
Do you have an autism diagnosis for the individual with autism up to age 21?* This field is required.
Yes, I have an autism diagnosis from my pediatrician or family doctor but do not have a comprehensive diagnostic report.
Yes, I have a comprehensive diagnosis report and an autism diagnosis from family doctor or pediatrician.
I will check the OASN Resource Guide to get a referral for an autism diagnosis and/or need a referrral to get an autism diagnosis.
Other
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Please attach your comprehensive diagnostic report, or initial diagnostic report with a diagnosis of autism (F84.0).
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Age* This field is required.
6
Developmental age (if developmentally delayed, if not, skip to birth date)
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Gender* This field is required.
Male
Female
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Birth Date* This field is required.
Month
Day
Year
9
Are you completing this form for:* This field is required.
my child up to age 18
for my grandchild
my young adult (ages 18-21)
I am a young adult completing this intake form
Other
10
Do we have your permission to forward your 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.
Other
11
Do you need information about the Empowerment Unique Abilities Scholarship (a scholarship that you can utlize to leave public school with an IEP, autism diagnosis or other qualified diagnosis?* This field is required.
YESNO
12
Are you a current recipient of the Empowerment Unique Abilities Scholarship (formerly Gardiner and McKay)?* This field is required.
YESNO
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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
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Parent/Guardian # 1 Name:* This field is required.If this is a young adult completing this application, please put not applicable or NA
15
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
16
Alternative Phone Number Parent #1
Area Code
Phone Number
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Parent/Guardian #1 E-mail* This field is required.
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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.
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Parent/Guardian # 2 Cell Number
Area Code
Phone Number
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Alternative Phone NumberParent #2
Area Code
Phone Number
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Parent/Guardian #2 E-mail
example@example.com
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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.
23
Image FieldPlease look at this chart and tell us your family size & income level based upon the 2023 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.
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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 $20,628)* 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
Other
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Ethnicity* 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.
Hispanic
Non Hispanic
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Race* 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.
White
Black/African American
Asian
More than one race
Unreported
Other
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Who referred you to OASN (if applicable)
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Please describe any current issues the individual with autism up to age 21 is experiencing.
29
Does the individual up to age 21 have any co-morbid (additional) diagnoses? If so, please list them.
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Does the individual up to age 21 have any of the following?
Seizures
Visual Impairment
Hearing Impairment
Medication or Food Allergies
Other
31
Does the individual up to age 21 have a special diet? If so, please let us know here.We want to make sure your wishes are being respected if your child participates in any of our programs or services. Thank you!
32
Does the individual up to age 21 have allergies? If so, please list them. If none, please notate here. * This field is required.
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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.OaSN would like to know every supplement and/or medication taken so that if we are caring for your child or making parent suggestions, we know what is currently being taken. Thank you!
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Is child with autism potty trained? This question can be skipped if you are a young adult or feel it does not apply.
YESNO
35
Please provide medical insurance information for individual with autism up to age 21:* This field is required.Please be as complete as possible to better serve you and your child.
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Is your insurance offered through* This field is required.
Medicaid (through DCF)
Healthy Kids funded
Private insurance (not through Healthcare.gov)
Private insurance 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.
Other
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Name of individual's (up to age 21) Doctor, ARNP or Primary Care Provider (please include phone number)* This field is required.
38
Does the individual with autism up to age 21 currently receive special education services?* This field is required.
YESNO
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Please list any current school-based services child with autism receives (Speech therapy, Occupational therapy, Behavioral services, TUB unit, EBD, etc). If none, or not applicable, please notate here. * This field is required.
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Current school-based services that the child receives (skip this question if not applicable):(if not listed, please type the answer in the box labeled other)
Speech therapy
Occupational therapy
Physical Therapy
ABA Therapy
My child does not receive school based services.
My child is in a TUB unit.
Other
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What supports are provided in the school/academic setting to ensure safety and the best learning environment?Ex: Self contained classroom, TUB, Access Points, ESE, etc.
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Does your 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
Other
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Please list name of current school/home education program/daycare/facility or program that individual with autism 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.
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Phone Number of school, home education program, daycare, ADT or facility listed above.
Area Code
Phone Number
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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
46
Would you like assistance getting ABA (applied behavioral analysis-life, social skills & behavioral management therapy) for your child?
YESNO
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Do you need assistance with academic options?* This field is required.
I am seeking academic placement for my child (private school, daycare, home education, different public school, ADT, etc).
I do not need assistance.
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Communication Abilities* This field is required.Select all that apply
No issues with communication/is full verbal.
No discernible speech sounds (mute or 1-2 sounds)
3-5 discernible speech sounds
Babbling consisting of 5+ speech sounds
Can say at least 10 words
Speaks but has trouble expressing him or herself
Echolalic (repetitive speech)
Uses words or short phrases to communicate wants, needs, and label things
Primary mode of communication is sign language
Primary mode of communication is technological device
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Approximate number of signs individual with autism (up to age 21) uses- ASL:If ASL is not used, please skip this question.
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Communication device used: Skip this question if a communication device is not used.
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Vocal or Motor-Stimulating BehaviorsSelect all that apply
Hand Flapping
Spinning
Rocking
Mouthing/Chewing
Making noises
Saying repetitive phrases
NONE
Other
52
Does the individual with autism 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.
53
Does the individual with autism up to age 21 respond to sudden environmental changes * This field is required.ex: loud noise, presence/absence of people
YESNO
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If your child/young adult/or young adult completing this form has meltdowns, are there triggers that you have noticed before a meltdown starts? What interventions have been helpful to your child/young adult when he/she has a meltdown?* This field is required.If your child/young adult/or young adult completing this form does not have meltdowns, please type N/A below.
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Does the child/young adult/or young adult completing this form exhibit verbal aggression? If so, how often?Times per day, week, etc.
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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.
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Does the child/young adult wander (leave an area with no apparent destination)?* This field is required.
YESNO
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Check all requested services that assistance is needed with:* This field is required.Check none if you are not requesting any of the below listed items.
Visual Prompts/Aids
Grooming
Dressing
Eating
Bathing
Referrals to providers
None
Toilet Training
Other
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Please utilize this area to ask our staff questions or provide us with additional information.
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Please attach your autism diagnosis, 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 for identification purposes. Thank you.
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OASN reserves the right to refuse services based on the following:

-Parent or guardian of individual with autism or adult (18-21 years old) individual with autism mistreating 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 autism 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 get free 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.
-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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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). Furthermore, I will not hold OASN, it's 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.
Clear
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