Request An Appointment
A FASD diagnostic evaluation is conducted in a single 4-hour appointment.
To request an appointment for a FASD diagnostic evaluation at one of The Florida Center’s FASD Clinic, please complete and submit our New Patient Information Form (NPIF). The NPIF allows you to share with us your concerns about the patient and why you are seeking a FASD diagnostic evaluation. To be seen at our FASD Clinic, an individual must have confirmed or it’s strongly suspected prenatal alcohol exposure history. We see patients of all ages (newborn to adult).
There are 3 ways you can obtain our New Patient Information Form:
1. Download the NPIF: You can download the NPIF by clicking here. Complete the form and email us back with “Appointment Request” in the subject line and the completed NPIF included in the email as an attachment.
2. Call Us to Receive the NPIF in the Mail: You can also obtain the NPIF by calling The Florida Center for Early Childhood (home to Florida's only Fetal Alcohol Diagnostic & Intervention Clinic) at (941) 371-8820, ext. 1040. You will be asked to leave the contact information noted below in point number three (3). We will mail the NPIF to you, with instructions for how to complete and submit the form to us.
3. Email Us to Receive the NPIF in the Mail: Using the contact form below (fill-in-the-blank boxes), you can obtain the NPIF by contacting the Clinic with the words “Appointment Request” as the first line in the comment box. Make sure you provide the first and last name of the person to be evaluated as well as their date of birth (month, day and year) and the address where you would like the New Patient Information Form to be mailed. Once this form is complete, press the submit button. Upon receipt of your request, we will mail the NPIF to you, with instructions for how to complete and submit this form back to us.
Please provide this information if you are requesting we mail/email the NPIF to you:
- Your first and last name.
- Your area code and telephone number.
- The first and last name of the person to be evaluated.
- The date of birth of the person to be evaluated (please tell us the month, day and year of the birth).
- The address you would like the NPIF to be sent to.
When we receive your completed NPIF, we will review it and contact you informing you of the status of your request and when you can expect an appointment.