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Referral to the Laguna Beach Unified School District's School Readiness Program
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Email *
Child's First and Last Name *
Parent(s) and/or Caregiver (s) Names *
Home Address (street, city, state, zip) *
Best Contact Phone Number (XXX-XXX-XXXX) *
Child's Date of Birth (Month/Date/Birth Year) *
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Child's Gender *
What is the primary language spoken in the home for the child and parent/caregiver? *
Race/Ethnicity of the Child *
Race/Ethnicity of Parents/Caregivers *
Required
Does this child fall within the district boundaries to attend school in Laguna Beach? *
Is this child currently enrolled in preschool and do they have any concerns? *
If yes, which preschool does this child attend? *
Required
Please summarize your concerns about your child's development? *
Describe your child's pertinent medical history and current health? (e.g. prematurity, allergies, ear infections, ear tubes, seizures.)
What percentage of your child's speech do you understand?
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What percentage of your child's speech does his/her preschool teacher or an unfamiliar listener understand?
Do you have any concerns about your child's ability to understand language? *
Do you have any concerns about your child's expressive language development?
How does your child express his/her needs, wants, and feelings? (i.e. pointing, single words, phrases, gestures, grunting, etc.) *
Is your child stringing words together Please give an example.
Does your child understand and follow directions at home or in a school setting? Please give an example.
How are your child's transitions? (preferred vs. non preferred and away from parents)
Do your child have an interest in playing with peers?  Do they use language while engaging and interacting with peers? 
Does your child sit and listen to you while reading a book?
How is your child's fine motor control? (e.g. scribbling, drawing, doing puzzles, getting dressed, open/close containers)
Is there any additional information that you'd like to share about this child?
A copy of your responses will be emailed to the address you provided.
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