Request for Child Find Screening
This screening is for children ages 6 months to 5 years old.
Requests are accepted by the child's parent or legal guardian. Are you the parent or legal guardian? *
Parent/Guardian Name(s) *
Your answer
Street Address: *
Your answer
City, State, & Zip: *
Your answer
Phone Number *
Your answer
Email *
Your answer
What is the child's date of birth? *
MM
/
DD
/
YYYY
What is your child's first, middle, and last name? *
Your answer
Gender: *
Primary Language: *
Your answer
Ethnicity: *
Required
What is your current county of residence? *
Who does the child live with? *
I have concerns about my child in the following areas: *
Examples: development, speech, vision, hearing, motor skills, behavior, etc.
Your answer
Does your child currently have any medical diagnosis? *
Your answer
Child's Pediatrician: *
Your answer
How did you hear about Child Find? *
Your answer
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