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ADULT FASD DIAGNOSTIC CLINIC REFERRAL FORM CLIENT INFORMATION Name:Date of referral:Date of Birth:Phone:Health Care Number:Home Community:Ethnicity: Dene Inuit Metis Indigenous Metis First Nation
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01
Gather all necessary personal information and documentation, such as medical records, educational records, and any previous assessments or evaluations.
02
Contact the adult FASD diagnostic clinic and schedule an appointment.
03
Attend the appointment and participate in the diagnostic assessment process.
04
Provide honest and accurate responses to any questions or interviews conducted by the clinic staff.
05
Cooperate with any additional assessments or tests deemed necessary by the clinic.
06
Follow any instructions or recommendations provided by the clinic after the assessment.
07
Maintain regular communication with the clinic to track progress or address any concerns.
08
Keep a record of the diagnosis and any treatment plans or interventions recommended by the clinic.

Who needs adult fasd diagnostic clinic?

01
Adults who suspect they may have Fetal Alcohol Spectrum Disorder (FASD) or individuals who display symptoms commonly associated with FASD.
02
Parents, caregivers, or healthcare professionals who are concerned about an adult's cognitive, behavioral, or developmental difficulties that may be attributed to FASD.
03
Individuals seeking a formal diagnosis of FASD for personal understanding, validation, or access to appropriate support services and accommodations.
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An adult FASD diagnostic clinic is a specialized medical facility that evaluates and diagnoses individuals for Fetal Alcohol Spectrum Disorders (FASD) in adults, utilizing clinical assessments, interviews, and standardized tools.
Individuals suspected of having Fetal Alcohol Spectrum Disorders and health professionals caring for them may be required to submit evaluations and documentation to an adult FASD diagnostic clinic for appropriate diagnosis and support.
To fill out the adult FASD diagnostic clinic forms, patients or their guardians should provide detailed personal and medical histories, answer questionnaires regarding behaviors and symptoms, and submit any relevant documentation from previous assessments or treatments.
The purpose of an adult FASD diagnostic clinic is to accurately diagnose FASD, provide appropriate support and resources, facilitate access to treatment, and improve the quality of life for individuals affected by FASD.
Information that must be reported includes personal identification details, medical history, assessment results, referral sources, and any previous diagnoses related to FASD or other mental health conditions.
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