FUN MAIL!

Address

Servicing The Florida Space Coast

Contact

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how did you hear about us?

Whether it was a friend, your care team, community event, or happy accident—
we’d love to know what led you here!

New Client Intake Form

First Name of Person Completing Form

Last name of Person Completing Form

Email (required)

Complete First, Middle and last Name of incoming client if a different person is completting the form (required)

Birthday of Incoming Client

Best Contact Phone Number

Address Details

Country/Region (required)

Address (required)

City (required)

Zip / Postal code (required)

Primary Insurance Provider (required)

Primary Insurance Card Front (required)

Primary Insurance Card Back (required)

Does the incoming client have a secondary insurance?* (required)

YesNo

Secondary Insurance Card Front

Secondary Insurance Card Back

Does the incoming client have an autism diagnosis from within the last three years? If so, please submit the diagnostic report below* (required)

Comprehensive Diagnostic Evaluation (CDE) that includes tool used:

Referrals

Do the client attends school?

How did you hear about Function First Florida