OASN Support Meeting Registration

1
Please let us know if you which Wednesday of the month by selecting a date below:* This field is required.Please note, all support meetings are offered 12pm-12:30pm (if time permits, we may go longer). Please note, subject to change due to school breaks, participation, etc. Call us for any questions (352) 462-0168.
Date
Year
Month
Day
2
Your Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.To be used in case of emergency cancellation of this support meeting or to ask questions about your child/adult with a neurodevelopmental disorder.
Area Code
Phone Number
4
Email* This field is required.
example@example.com
5
Do you or the individual with a neurodevelopmental disorder you are requesting support for have an intake form on file (after January 1, 2022)?
YESNO
6
Please list the name of the person that has an intake form on file with OASN:
First Name
Last Name
7
Are you a* This field is required.
Parent of a child with a neurodevelopmental disorder (up to 18)
Parent of a child with adult child with a neurodevelopmental disorder (over the age of 18)
Individual with a neurodevelopmental disorder (adult)
Caregiver of a child with a neurodevelopmental disorder (up to 18)
Caregiver of an adult with with a neurodevelopmental disorder (over the age of 18)
Medical or Therapeutic Professional providing services to individual with a neurodevelopmental disorder
Other
8
If there is anything you would like our staff to know please type it in here:(If you need a return call, please give us a phone number to reach you)
Should be Empty: