• Human Development Center

    Building Capacity, Inspiring Change

  • ASDID Clinic Application Packet

  • Introduction

  • Thank you for your interest in the Autism Spectrum Disorder Interdisciplinary Diagnostic (ASDID) Clinic at the LSUHSC Human Development Center. The purpose of the ASDID clinic is two-fold:

    1. To provide an outstanding diagnostic service to families of children suspected of having autism spectrum disorder (ASD).
    2. To provide high-quality information, training, and supervision to pediatric medical residents, graduate students, professionals, and families about best practices in family partnerships and interdisciplinary teaming and evaluations. Participating disciplines may include audiology, early childhood intervention, medicine/pediatrics, occupational therapy, physical therapy, psychology, public health, special education, and speech-language pathology.

    The clinic team works together to engage in best practices for ASD assessment, diagnosis, and support for children and their families. 

    Please complete this form to the best of your ability. We recognize that you may not have the answers to all questions. If you feel that there is not enough room or that you would like to elaborate further about a particular topic, please feel free to include it at the space provided at the end of the packet. All information requested in this form is important and will allow us to provide you with the most accurate diagnosis and care plans. Thank you for taking the time to complete it. If you have questions about completing this form or the process for the clinic, please contact Lisa Davison [email protected].

  • Your Child

  • Child Date of Birth*
     / /
  • Race (from US Census list)*
  • Ethnicity - Hispanic refers to the ethnic communities of Spain or any Spanish-speaking country. A person from any race can be Hispanic.*
  • Does your child already have an ASD diagnosis?*

  • Parent/Guardian Information

  • What is the Relationship of Parent/Guardian #1 to Child*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is the Relationship of Parent/Guardian #2 to Child*

  • Percentage of time that child lives with:
    Mother *   
    Father   *      
    Other    *        

  • Who is the legal guardian of the child?*
  • Who does the child primarily live with?*
  • Both parents/guardians are aware that services are being requested from LSUHSC ASDID Clinic.*

  • Siblings and Other Family Members

  • Emergency Contact

  • Format: (000) 000-0000.

  • Healthcare Provider Information

  • Has the pediatrician or anyone else on your child's medical team indicated concerns about the following: (Check all that applies)
  • Has the anyone (e.g., child's primary care physician, pediatrician, teacher, relative) ever expressed concerns about any of the following? (Check all that apply)
  • Not including Early Steps, has the child received any of the below therapies or services? (Check all that apply)

  • Early Intervention, Education and School Services

  • Does the child attend a child care center, an early learning center or school?*
  • What grade is your child in?*
  • Has your child's teacher or anyone else at school indicated concerns about the following: (Check all that applies)
  • Has your child ever been evaluated for Early Steps Services?*
  • Does your child qualify for Early Steps Services?*
  • Has your child currently or ever received services from Early Steps?*
  • Does your child have an individualized Education Plan (IEP)?*

  • Your referral application to the LSUHSC ASDID clinic is now complete. Please click or tap the Submit button to finalize your submission.

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