ASD Registration Form

This is the registration for the Autism Spectrum Disorders (ASD) Program for residents of Boulder County, Colorado. Please complete the form below and click 'Submit'. Your computer browser will then be returned to the Imagine! ASD Program web site. The ASD Program Coordinator will email you an ASD Registration Confirmation within 3-4 days. Intake Case Management at Imagine! will mail you an Intake Application Packet which must be promptly completed and returned before ASD Program enrollment can be given further consideration.

First Name*
Middle Name
Last Name*
DOB*
Gender*
Siblings (checkbox)
Local School District
Primary Language Spoken
Autism Spectrum Disorder*
Address Line 1
Address Line 2
City
County*
State
Zip
Parent/Guardian First Name*
Parent/Guardian Last Name*
E-mail*
Phone Number
ASD Referral Source
Comment

Please Check the box below.





1) By submitting this form you are identifying your family member as having a diagnosis of an autism spectrum disorder.

2) Within 8 weeks of today’s date, you will need to submit supporting documentation of medical diagnosis to the ASD Program Coordinator. This should be a copy of the most recent document(s) supporting a diagnosis, defined in DSM-V as Autism Spectrum Disorder (OR under DSM-IV with Autism, Asperger's Syndrome, PDD-NOS, Rett Syndrome, or Childhood Disintegrative Disorder). A licensed psychiatrist, physician, or psychologist who specializes in autism spectrum disorders should sign these documents. A formal cognitive assessment (not play based) is also requested and often a triennial school IEP will include this. Fax to ASD Program: 303 665-2648. Email to: jshields@imaginecolorado.org. Mail to: Imagine!, Attn: ASD Program, 1400 Dixon Ave, Lafayette CO 80026-2790.

3) Additionally, you must contact the Imagine! Intake Case Manager at 303-926-6475 within 8 weeks of today’s date to schedule an eligibility review, unless you have previously received a letter of denial of eligibility from Imagine! or another community centered board.

4) On July 1st of each year, we enroll 15 individuals. If you receive notification of enrollment, you will gain access to your personal website to create a 3 Year Plan for services, order services from contracted service providers, track ordered services and manage funds. Completion of a 3 Year Plan for use of funds is required before funds can be accessed.

5) For general information about the ASD Program you may call Imagine! at 303-926-6444. For supports and direction for your family member contact the Autism Society of Boulder County at 720-272-8231 or www.autismboulder.org.

6) Please maintain current email, phone number and mailing address on record with ASD Program Coordinator.